THE TECHNIQUE OF THE NORMOTHERMIC AND HYPOTHERMIC TOTAL HEPATIC VASCULAR EXCLUSION FOR RESECTION OF THE LIVER TUMORS

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Combined liver and inferior vena cava resection for hepatic malignancy

OBJECTIVE: The experience from a single center, in combined liver and inferior vena cava (IVC) resection for liver tumors, is presented. METHODS: Twelve patients underwent a combined liver resection with IVC replacement. The median age was 45 years (range 35-67 years). Resections were carried out for hepatocellular carcinoma (n = 4), colorectal metastases (n = 6), and cholangiocarcinoma (n = 2). Liver resections included eight right lobectomies and four left trisegmentectomies. The IVC was reconstructed with ringed Gore-Tex tube graft. RESULTS: No perioperative deaths were reported. The median operative blood transfusion requirement was 2 units (range 0-12 units) and the median operative time was 5 hr. Median hospital stay was 10 days (range 8-25 days). Three patients had evidence of postoperative liver failure, resolved with supportive management. Two patients developed bile leaks, resolved conservatively. With a median follow up of 24 months, all vascular reconstructions were patent and no evidence of graft infection was documented. CONCLUSIONS: Aggressive surgical management of liver tumors, offer the only hope for cure or palliation. We suggest that liver resection with vena cava replacement may be performed safely, with acceptable morbidity, by specialized surgical teams.     

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. J. Surg. Oncol. 1999;72:50–56. © 1999 Wiley-Liss, Inc.     

Selective hepatic vascular exclusion and Pringle maneuver: A comparative study in liver resection

Objective

Most liver resections require champing of the hepatic pedicle (Pringle maneuver) to avoid excessive blood loss. But Pringle maneuver cannot control backflow bleeding of the hepatic vein. Resection of liver tumors involving hepatic veins may cause massive hemorrhage or air embolism from injuries of the hepatic vein. Although total hepatic vascular exclusion (THVE) can prevent bleeding of the hepatic vein effectively, it also may result in systemic hemodynamic disturbance because of the clamped inferior vena cava (IVC). SHVE, a new technique, can control the inflow and outflow of the liver without clamping the vena cava. We compared the effects of selective hepatic vascular exclusion (SHVE) and Pringle maneuver in resection of liver tumors involving the junction of the hepatic vein.

Methods

From January 2000 to October 2005, 2100 patients with liver tumors had undergone liver resections in our department. Among them, tumors of 235 cases adhered to or were close to the junction of one or more hepatic veins. Both SHVE and Pringle maneuver were used to control blood loss during hepatectomy. These 235 cases were divided into two groups: Pringle maneuver group (110) from January 2000 to December 2002 and SHVE group (125) from January 2003 to October 2005. Data were analyzed regarding the intraoperative and postoperative courses of the patients. In the SHVE group, total SHVE (clamping the porta hepatis and all major hepatic veins) was used in 69 cases and partial SHVE (clamping the porta hepatic and one or two hepatic veins) in 56 cases. There were three methods in hepatic veins occlusion: ligating with suture, encircling and occluding with tourniquets and clamping with Satinsky clamps.

Results

There was no difference between the two groups regarding the age, gender, tumor size, cirrhosis and HBsAg rate, ischemia time and operating time. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group. Hepatic veins rupture with massive blood loss occurred in 14 and air embolism in three during the tumor resection, but there was no massive blood loss and air embolism in the SHVE group due to hepatic vein occlusion. Postoperative bleeding, reoperation, liver failure and mortality rate were higher, and ICU stay and hospital stay were longer in the Pringle group than those in the SHVE group.

Conclusion

SHVE is much more effective than Pringle maneuver in controlling intraoperative bleeding. It can prevent massive blood loss and air embolism from hepatic veins rupture and can reduce the postoperative complication rate and mortality rate. Clamping the hepatic veins with Satinsky clamps is much safer and easier than ligating with suture and occluding with tourniquets.     

Complex liver resection for hepatic tumours involving the inferior vena cava

Background

Resection of liver tumours with involvement of inferior vena cava (IVC) is considered to have a high surgical risk.

Aim

We retrospectively reviewed 23 patients who underwent hepatectomy with IVC resection in two West-European liver surgery Units.

Methods

The tumours included liver metastases (n = 13), hepatocellular carcinoma (n = 4), intrahepatic cholangiocarcinoma (n = 3), liver haemangioma (n = 1), primary hepatic lymphoma (n = 1) and recurrent right adrenal gland carcinoma (n = 1).

Results

IVC resection was associated with right hepatectomy in 8 cases, extended right hepatectomy in 9 cases, extended left hepatectomy in 3 cases, minor liver resection in 2 cases, and right hepatectomy with nephrectomy in one case. In 16 patients the IVC wall involvement was <30% of its circumference, and a tangential vena cava resection was performed. In 7 patients (30%) with >50% involvement, a caval segment was resected and replaced with a 20 mm ringed polytetrafluoroethylene graft. R0-resection was achieved in all patients. Median intraoperative blood loss was 1.100 ml (range 490–15,000). Fourteen patients were transfused with a median of 3 PRC units per patient (range 1–25). Major complications occurred in 9 patients. Postoperative stay in ICU was 2.3 ± 3.4 days (range 1–14) and hospital stay was 17.3 ± 2.6 days (range 5–62). In 14 patients, final pathology demonstrated microscopic IVC infiltration.

Conclusions

In selected patients with malignant involvement of the liver and IVC, surgical resection en bloc with IVC is the only possibility to achieve R0 resection, with acceptable mortality and morbidity, in units specialized in liver surgery.     

Hepatocellular carcinoma: resection with adjuvant hepatic artery infusion therapy vs resection alone. A systematic review and meta-analysis

Hepatocellular carcinoma (HCC) has a recurrence rate of up to 70% in 5 years after resection, detrimentally lowering survival. The role of adjuvant therapy remains controversial; therefore, the aim of this study was to evaluate the disease-free and overall survival of patients with HCC, not candidates for transplantation, undergoing resection and adjuvant hepatic artery infusion therapy vs resection alone. Our meta-analysis showed that adjuvant HAIC improves overall and disease-free survival after resection, especially in tumors ≥7 cm.     

选择性出入肝血流阻断在肝脏巨大肿瘤切除术中的应用

目的 探讨选择性出入肝血流阻断(SHVE)在肝脏巨大肿瘤切除术中应用的优势.方法 回顾性分析29例施行肝脏巨大肿瘤切除术患者的临床资料,随机分为SHVE组(15例)和第一肝门阻断组[(Pringle组),14例],比较两组患者的术中肝血流阻断时间、肝切除范围、出血量、术后肝功能恢复情况、术后2 d平均腹腔引流量以及并发症发生率等指标.结果 两组患者的性别、年龄、肿瘤大小、术中肝血流阻断时间以及肝切除范围的差异均无统计学意义(P＞0.05).SHVE组患者的术中出血量为(282.1±286.5)ml,明显少于Pringle组[(721.5±512.1)ml,P＜0.05].SHVE组患者术后第1、3、7天血清前白蛋白含量明显高于Pringle组(P＜0.05),血清谷丙转氨酶和总胆红素含量明显低于Pringle组(P＜0.05).SHVE组患者术后2 d平均引流量为(189.4±103.5)ml,明显少于Pringle组[(249.5±108.7)ml,P＜0.05].Pringle组有1例发生肝功能衰竭,SHVE组无一例发生肝功能衰竭.Pringle组有4例发生肝静脉损伤,3例发生肝静脉破裂大出血,1例发生空气栓塞;SHVE组虽有5例发生肝静脉损伤,但无一例发生肝静脉破裂大出血或空气栓塞.结论 SHVE术可以提高肝脏巨大肿瘤切除患者对手术的耐受性,是合理安全的肝脏手术术式.     

Liver metastases in close contact to hepatic veins ablated under vascular exclusion

Background

Liver metastases (LM) in close contact to hepatic veins (HV) are a frequent cause of unresectability. Reconstruction of hepatic veins is technically difficult and outcomes are poor. Intra-operative radiofrequency ablation (IRFA) with vascular exclusion (VE) may be a useful approach.

Methods

Out of 358 patients operated for LM, 22 with LM close to a HV treated by IRFA under VE with at least one year of follow-up were included in this retrospective study. Technical success was evaluated at four months by CT scan of the ablated lesion. Complications; local, hepatic and extra-hepatic recurrence rates, and overall survival are reported.

Results

The median number of metastases was 4.5 [range: 1–12]. Seventeen patients had bilateral metastases. The median size of ablated lesions was 2 cm [range: 1–5.5]. Seven complications occurred (1 Grade 1, 2 Grade 3b and 4 Grade IVa), with no mortality. No recurrence of ablated lesions was detected at four months or during follow-up. Seventeen patients had new or extra-hepatic lesions. Median overall survival for colorectal patients was 40 months 95%CI[17.5-not reached].

Conclusions

IRFA plus VE for LM in close contact to a HV is a novel approach, appearing to be a safe and effective technique which can extend the applications of liver metastases surgery.     

Normothermic total hepatic vascular exclusion for hepatectomy

Experience of normothermic total hepatic vascular exclusion for hepatectomy in two patients with hepatocarcinoma in the second porta hepatis area are reported. The combined method of stepwise exclusion of porta hepatis, total hepatic vascular exclusion, total hepatic vascular exclusion without abdominal aorta and manipulative exclusion of inferior vena cava above liver are described. Biochemical studies before, during and after the operation showed that they are similar to these of routine hepatectomy. This modification, being safer and easier, may increase the resectability and reduce the mortality rate.     

中央型结直肠癌肝脏转移瘤同期手术治疗分析

探讨中央型结直肠癌肝脏转移瘤同期手术的可行性及疗效。方法：回顾并分析了中国医学科学院肿瘤医院从1995年1月至2010年12月间23例同期中央型结直肠癌肝脏转移瘤同期手术的患者,分析疗效。结果：男性16例,女性7例,年龄34～68岁,无手术死亡病例。手术时间（306±7.2） min,术中出血（421±12.6） mL。术中输血者6例,住院天数（11.4±1.8）天。手术并发症：胸腔积液4例,胆漏1例,下肢静脉血栓1例。均治愈。术后随访至2010年12月。1、3、5年生存率分别为：74.0%,48.5%,17.0%。术后1周内肝功能均恢复至ChildA级。结论：选择性肝区域血流适时阻断配合超声乳化吸引刀同期行中央型结直肠癌肝转移瘤切除术比较安全可行,疗效较满意。     

Short time to recurrence after hepatic resection correlates with poor prognosis in colorectal hepatic metastasis

BACKGROUND: Early recurrence is a major problem after hepatic resection of colorectal hepatic metastasis (CHM). Our aim was to investigate the relationship between time to recurrence after CHM resection and overall survival. METHODS: A retrospective analysis was performed for 101 consecutive patients who underwent hepatic resection for CHM and have been followed more than 5 years. RESULTS: Among 101 patients, 82 (81%) had a recurrence. Overall survival of patients with recurrence within 6 months after CHM resection was significantly worse than that of patients with recurrence after more than 6 months (P < 0.01). Overall survival was poorer when time to recurrence was shorter. One of the reasons for poor prognosis of patients with recurrence within 6 months was that only a few patients could undergo a second resection for recurrence after CHM resection. Histological type, including poorly differentiated signet ring cell or mucinous adenocarcinoma in the primary tumor, bilobar metastases, microscopic positive surgical margin and carcinoembryonic antigen (CEA) above 15 ng/ml had predictive value for decreased recurrence-free survival after CHM resection. CONCLUSION: Short time to recurrence after CHM resection correlates with a poor prognosis. Histological type of poorly differentiated signet ring cell or mucinous adenocarcinoma in the primary tumor might be a predictor for early recurrence after CHM resection.     

THE ROLE OF TARGETING THERAPY IN CYTOREDUCTION AND SEQUENTIAL RESECTION OF UNRESECTABLE HEPATOCELLULAR CARCINOMA

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Precoagulation with microwave ablation for hepatic parenchymal transection during liver partial resection

Purpose: To evaluate the feasibility of precoagulation with microwave ablation (MWA) for hepatic parenchymal transection during liver partial resection.

Methods: A total of 66 eligible patients were enrolled in this double-blind, randomized, controlled study. Patients were randomized to receive either the traditional clamp-crushing method (Control group) or the MWA precoagulation method (MWA group) for hepatic parenchymal transection during liver partial resection. The operative time, hepatic portal occlusion time, intraoperative blood loss and transfusion, postoperative complications and recovery outcomes were compared.

Results: Compared to the Control group, the MWA group had significantly less intraoperative blood loss. Fewer red blood cell transfusions were observed in the MWA group but without statistical significance. The MWA group showed significantly higher serum alanine aminotransferase and aspartate aminotransferase levels at day 1 postoperatively, but no differences between the MWA and Control groups were found at days 3 and 7. There were no significant differences in terms of operative time, hepatic portal occlusion time, postoperative total bilirubin levels, human albumin solution consumption or length of hospital stay. Postoperative complications such as impaired renal function, pyrexia, admission to ICU, abscess, biliary leakage, intrahepatic and distant tumor recurrence and in-hospital mortality were comparable between the two groups.

Conclusion: Precoagulation with MWA reduced intraoperative blood loss with similar postoperative complications, providing a safe, effective, novel alternative for hepatic parenchymal transection during liver partial resection. Additional results from larger series are recommended to confirm these findings.     

Extent of hepatic resection does not correlate with toxicity following adjuvant chemotherapy

BACKGROUND: In patients with liver metastases from colorectal cancer, survival can be increased by hepatic resection. Treatment with hepatic arterial infusion (HAI) and systemic chemotherapy following resection may further increase survival and decrease recurrence, but may also result in hepatic and systemic toxicity. This article will address the question of whether large hepatic resections resulting in a greater loss of healthy liver predisposes patients to developing toxicity from the subsequent chemotherapeutic regimens. DESIGN: Retrospective analysis of 88 patients who underwent liver resection of colorectal metastases followed by adjuvant HAI and systemic chemotherapy and whose computerized tomography (CT) scans were done at Memorial Sloan-Kettering Cancer Center (MSKCC). Liver volumes were calculated from CT scans and used to determine the percentage change in healthy liver volume between the pre- and post-operative CT scans. Hepatic and systemic toxicities were defined according to the Common Toxicity Criteria of the National Cancer Institute. RESULTS: Patients experienced a mean percentage decrease in healthy liver tissue of 17% (range: 57% decrease to 32% increase) at an estimated 1 month after resection and at the initiation of chemotherapy. In a logistic regression model using percentage change in the healthy liver volume as a continuous variable, no significant association was revealed between percentage of healthy liver resected and diarrhea (P = 0.47), leukopenia (P = 0.37), neutropenia (P = 0.31), high bilirubin (P = 0.27), or alkaline phosphatase (P = 0.79). CONCLUSIONS: A greater loss of healthy liver following resection of hepatic metastases from colorectal cancer does not seem to predispose to the development of toxicity from adjuvant HAI and systemic chemotherapy.     

Predictors of survival after hepatic resection among patients with colorectal liver metastasis

Studies suggest improved survival following resection of colorectal cancer liver metastases (CLMs). We investigated predictors of survival among patients with CLM who underwent hepatic resection using the SEER-Medicare database to identify patients >/=65 years diagnosed with CLM, 1991-2003, who underwent hepatectomy. Cox proportional hazards models were used to identify factors associated with survival after hepatectomy. Of 923 patients with CLM who underwent hepatectomy, 514 were stages I-III and developed CLM>6 months after diagnosis (metachronous), and 409 were stage IV with CLM at diagnosis (synchronous). From the date of hepatectomy, 5 year survival was 22%; younger age, being married, female gender, surgery in an NCI-designated cancer centre, fewer comorbidities, fewer positive lymph nodes, and lower grade were associated with improved survival. Both 5-fluorouracil (5FU)-based chemotherapy and hepatic arterial infusion (HAI) of floxuridine-based chemotherapy following hepatectomy improved survival (HR=0.62, 95% CI: 0.50-0.78; HR=0.51, 95% CI: 0.28-0.97, respectively) in the synchronous, but not metachronous, group. The HR for overall mortality was higher in hospitals with a high vs low procedure volume (0.75, 95% CI: 0.58-0.94). A substantial subgroup of patients with CLM who undergo hepatectomy experiences long-term survival. High hospital procedure volume and use of 5FU-based or HAI-based chemotherapy after resection were associated with improved prognosis.     

Major hepatic resection may suppress the growth of tumours remaining in the residual liver

Little is known as to how hepatectomy is associated with the growth of hepatic tumours, which may reside in the remaining liver after curative resection for hepatocellular carcinoma. Using an intra-hepatic tumour implantation model in rats, the effects of hepatectomy on tumour growth in the remaining liver were investigated. On post-operative day 7, the tumour weight in the remaining liver following 30% hepatectomy was 0.321+/-0.058 g (mean +/- SD) which was significantly greater than that (0.245+/-0.040 g) in sham operations (P<0.05). However, the tumour weight (0.156+/-0.067 g) in the remaining liver following 60% hepatectomy was significantly lower than that in sham animals (P< 0.005). The number of TdT-mediated dUTP nick-end labelling (TUNEL) positive tumour cells was significantly increased in 60% hepatectomy as compared with the sham and 30% hepatectomy group. The mRNA expression of TGF-beta1, TNF-alpha and Fas in the tumour portion of 60% hepatectomy, was higher than that in 30% hepatectomy group. Plasma levels of TGF-beta1 were inversely correlated with intra-hepatic tumour weights. These results suggest that major hepatic resection may lead to an increased induction of apoptosis for the remaining hepatic tumour.