Right hepatectomy combined with retrohepatic caval resection,using a left renal vein patch graft for advanced cholangiocarcinoma

Combined resection of the inferior vena cava for hepatobiliary malignancies remains a technical challenge. We successfully resected an intrahepatic cholangiocarcinoma involving the retrohepatic vena cava, and reconstructed the caval defect using a left renal vein patch graft. The patient was a 79-year-old man. Preoperative ultrasonography and computed tomography revealed that the tumor was located in the right lobe of the liver and was about 6?cm in diameter. Arteriogram revealed encasement of the right arterial and portal branches. Magnetic resonance imaging scan revealed that the tumor involved the retrohepatic vena cava. The patient underwent a right hepatectomy combined with resection of the retrohepatic vena cava. The resected portion of the caval wall was 3.6?cm long and 2.7?cm wide. The caval defect was reconstructed using a left renal vein patch graft of a rhomboid shape, which was made by oblique incision of the vein graft. The postoperative course was uneventful. Postoperative cavogram showed adequate patency of the reconstructed retrohepatic vena cava. The patient was disease-free 22 months after surgery. In conclusion, major liver resection combined with caval resection and reconstruction can be performed safely. Furthermore, a left renal vein graft can provide a flexible patch according to the form and size of the caval defect.     

Successful treatment of conversion chemotherapy for initially unresectable synchronous colorectal liver metastasis

A 72-year-old woman with a sigmoid colon cancer and a synchronous colorectal liver metastasis(CRLM),which involved the right hepatic vein(RHV)and the inferior vena cava(IVC),was referred to our hospital.The metastatic lesion was diagnosed as initially unresectable because of its invasion into the confluence of the RHV and IVC.After she had undergone laparoscopic sigmoidectomy for the original tumor,she consequently had 3 courses of modified 5-fluorouracil,leucovorin,and oxaliplatin(m FOLFOX6)plus cetuximab.Computed tomography revealed a partial response,and the confluence of the RHV and IVC got free from cancer invasion.After 3 additional courses of m FOLFOX6 plus cetuximab,preoperative percutaneous transhepatic portal vein embolization(PTPE)was performed to secure the future remnant liver volume.Finally,a right hemihepatectomy was performed.The postoperative course was uneventful.The patient was discharged from the hospital on postoperative day 13.She had neither local recurrence nor distant metastasis 18 mo after the last surgical intervention.This multidisciplinary strategy,consisting of conversion chemotherapy using FOLFOX plus cetuximab and PTPE,could contribute in facilitating curative hepatic resection for initially unresectable CRLM.     

Cholangiocellular carcinoma in a patient who has survived for 6 years after extended left hepatic lobectomy and caudate lobe resection with pancreatoduodenectomy

We describe a case of cholangiocellular carcinoma in a 66-year-old woman. A well-defined, hypoechoic tumor, 9 cm in greatest diameter, was detected in the left lobe of the liver by ultrasonography in December 1988. Celiac angiography showed a faintly stained tumor at the same location, with interruption of the left portal vein. Computed tomography revealed invasion of the inferior vena cava and lymph node enlargement around the head of the pancreas. In January 1989, the patient underwent extended left hepatic lobectomy with caudate lobe resection, pancreatoduodenectomy, partial resection of the inferior vena cava, and lymph node dissection around the hepatoduodenal ligament and the common hepatic artery. Postoperative histopathological examination revealed a moderately differentiated tubular adenocarcinoma. Cancer cells had invaded only the portal region, unlike the features of most cholangiocellular carcinomas. There was no evidence of lymph node metastasis in the dissected specimens. Six years after operation, there have been no signs of recurrence, and the patient is still alive and well.     

Successful resection of cecal hepatic metastasis extending into the right side of the heart under cardiopulmonary bypass

Resection is the best hope for the cure of colorectal metastasis to the liver. However, surgery is indicated for only a few patients, especially those who have major vascular involvement. We report a 55-year-old woman with a liver metastasis from the cecum that showed a tumor thrombus in the right side of the heart. She had undergone laparoscopic right hemicolectomy for cecal cancer 6 months before, and presented with a palpable mass in the epigastrium. Abdominal ultrasonography, computed tomography, hepatic angiogram, and echocardiography showed a huge mass on the left lobe of the liver, with a tumor thrombus which extended to the right ventricle through the left hepatic vein and inferior vena cava. Tumor thrombectomy, through a right atriotomy, was success-fully performed under cardiopulmonary bypass, followed by left hepatic lobectomy. The patient's postoperative course was uneventful.     

Intravenous leiomyomatosis with extension to the heart: echocardiographic features: a case report

A 40-year-old female was admitted to the hospital for an operation with a presumptive diagnosis of right atrial myxoma. She had had a hysterectomy for leiomyoma 8 months earlier and has since experienced progressive dyspnea on exertion, pedal edema, and two syncope episodes in the past 2 months. Cardiac murmur was detected and two-dimensional echocardiography was arranged. A mobile right atrial mass was discovered, which was thought to be a myxoma. The patient subsequently received open heart surgery. Histologic examination of the resected mass confirmed intravenous leiomyomatosis. Magnetic resonance imaging performed on the eighth postoperative day revealed an intravascular mass from the right common iliac vein to the upper abdominal inferior vena cava. The patient underwent a second operation one and half months after the first operation, with resection of the tumor mass in the inferior vena cava and resection of multiple uterine myoma. She recovered well. Repeat magnetic resonance imaging 6 months following the second operation showed that the inferior vena cava and right atrium were clear of tumor.     

Hepatic resection through an anterior approach employing a modified liver hanging maneuver in patients with a massive liver tumor severely oppressing the inferior vena cava

For a large hepatic neoplasm existing in the right hepatic lobe, hepatic resection using an anterior approach is required. We have reported an operative procedure for hepatic transection using absorbable polyglycolic acid tape. In patients with suspected tumor invasion of the inferior vena cava, on the other hand, considering the range of the residual tumor while sparing the inferior vena cava as much as possible, combined resection and reconstruction of the inferior vena cava is conducted only if operative curativity is expected. We conducted hepatic transection while maintaining the blood flow of the residual liver by applying the liver hanging maneuver method of Belghiti et al. and polyglycolic acid tape in patients with giant liver tumors of the right hepatic lobe compressing the hepatic inferior vena cava. Strong angled dissecting forceps were inserted into the ventral side of the inferior vena cava from the caudal side, and the tip was induced between hepatic veins. Two strips of polyglycolic acid tape were pinched with forceps and strongly ligated on the right and left sides of the cutoff line. Subsequently, hepatic transection was conducted using electrocautery spray coagulation and CUSA without blocking the inflow blood of the residual liver, and the right hepatic lobe was extirpated. This procedure has already been performed in 5 patients suspected of inferior vena cava invasion, and the inferior vena cava was able to be preserved in all the patients.     

Aggressive surgical resection for hepatocellular carcinoma with tumor thrombus extending to inferior vena cava and synchronous pulmonary metastasis

We describe a 66-year-old man having hepatocellular carcinoma with tumor thrombus extending into the inferior vena cava and synchronous pulmonary metastasis. He was referred to Chiba University Hospital on May, 2000, complaining of emaciation. Radiological findings showed a huge hepatocellular carcinoma in the entire right lobe and tumor thrombus extended into the intrapericardial inferior vena cava. He also had a solitary pulmonary metastasis in the left pulmonary lobe (stage IVB). Right hemihepatomy was performed under total hepatic vascular exclusion without cardiopulmonary bypass, and tumor thrombus was completely removed. Thoracoscopic wedge resection of pulmonary metastasis was also performed. The patient had an uneventful postoperative course. Histopathological examination revealed that the tumor was moderately differentiated hepatocellular carcinoma The patient is still alive after 26 months with pulmonary recurrence, but without hepatic recurrence. To our knowledge, there has been no reported case of resection for both hepatocellular carcinoma invading the inferior vena cava and synchronous pulmonary metastasis. In conclusion, aggressive surgical resection for advanced hepatocellular carcinoma concomitant with pulmonary resection may bring about better prognosis in highly selected patients.     

Extended right hepatic lobectomy with resection of inferior vena cava and portal vein for intrahepatic cholangiocarcinoma

We report a case of intrahepatic cholangiocarcinoma treated by extended right lobectomy and resection of the inferior vena cava (IVC) and portal vein. A 53-year-old man was referred with elevated serum alkaline phosphatase (ALP) and γ-glutamyl transpeptidase (γ-GTP) levels on April 23, 1999. He was not jaundiced and did not have any symptoms. Endoscopic retrograde cholangiopancreatography (ERCP) revealed irregular strictures in both the anterior and posterior segmental ducts. Contrast-enhanced computed tomography (CT) scan demonstrated a low-density tumor with an unclear margin in the right lobe of the liver. The patient underwent extended right hepatic lobectomy and total caudate lobectomy. Partial resection of the IVC (6 cm) was performed under total hepatic vascular exclusion. The main portal trunk and left portal vein were resected and reconstructed with an end-to-end anastomosis. Macroscopically, a 5.0 × 5.0 × 4.5-cm periductal infiltrating-type tumor occupied the right hepatic parenchyma along the posterior and anterior segmental ducts. Histological examination revealed moderately differentiated tubular adenocarcinoma with marked perineural invasion. Lymph node metastasis was observed in the hepatoduodenal ligament and posterior surface of the pancreatic head. The resected margins of the common bile duct and left hepatic duct were free of tumor. The patient's postoperative course was uneventful, and he was discharged from hospital on the 28th postoperative day. Nine months after the operation, he suddenly developed obstructive jaundice, and died with recurrent disease. This is the first reported case of intrahepatic cholangiocarcinoma treated with major hepatectomy and resection of the IVC and portal vein except ex situ procedure. This aggressive surgical approach may offer hope for patients with intrahepatic cholangiocarcinoma involving the IVC.     

Right hepatic lobectomy and removal of inferior vena caval tumor embolus in a patient with hepatocellular carcinoma,using veno-venous bypass while preserving perfusion in the remnant liver: A case report

We describe a successful hepatectomy and the removal of a tumor embolus in a 43-year-old woman with hepatocellular carcinoma occupying the right lobe extending to the right branch of the portal vein and the inferior vena cava (IVC). Intraoperative echography revealed the tumor embolus in the IVC to originate from the main tumor via the right inferior hepatic vein, which extended cephalad from the confluence of the right hepatic vein to the IVC. Right hepatc lobectomy was performed via the anterior approach. Using femoro-axillary veno-venous bypass, we opened the IVC at the root of the inferior right hepatic vein to remove the tumor embolus after oblique clamping of the IVC between the right and middle hepatic veins was carried out to preserve perfusion in the remnant liver. Preserving perfusion in the remmant liver in radical hepatectomy for hepatocellular carcinoma with tumor embolism in the IVC appears to be a safe and advantageous technique in patients with poor liver reserve.     

Inferior vena cavectomy for renal cell carcinoma with intracaval tumor thrombus

Excision of the inferior vena cava for renal cell carcinoma with intracaval tumor thrombus is infrequently performed. Herein the authors report a 60-year old woman with a right renal cell carcinoma and massive occluding tumor thrombus of the inferior vena cava. Following a negative metastatic workup, this patient underwent surgery to remove the tumor and thrombus. Thrombectomy occurred via excision of the affected portion of inferior vena cava and proximal left renal vein. Reconstruction of the vena cava was not undertaken. The patient did not suffer any morbidity during recovery in hospital. Her renal function was normal upon discharge. All resection margins were negative for tumor. This experience is compared to those reported in the literature. Postoperative morbidity may be minimized by careful patient selection. Suitable patients should have a right-sided tumor with an occlusive subhepatic vena caval tumor thrombus.     

Leiomyosarcoma of the inferior vena cava invading into the liver. Complete resection with venous reconstruction]

A case of leiomyosarcoma of the retrohepatic inferior vena cava associated with metastasis in the right liver lobe is reported. Resection included extended right hepatectomy, right nephrectomy, and tumor--containing inferior vena cava resection followed by polytetrafluoroethylene tube reconstruction. A comfortable survival was obtained before multifocal malignant spread led to death 42 months after surgery.     

Congenital absence of the portal vein complicating hepatic tumors

Congenital absence of the portal vein (CAPV) is a rare malformation that is often accompanied by other anomalies such as cardiac and skeletal malformations and/or hepatic tumors. We describe here a case of CAPV complicating hepatic tumors in a 16-year-old Japanese girl. Abdominal ultrasonography revealed a hyperechoic tumor in the liver and dilatation of the portal vein that appeared to be connected directly with the inferior vena cava. Subsequent abdominal computed tomography (CT) revealed tumors and magnetic resonance angiography confirmed that the portal vein entered directly into the inferior vena cava just above the liver. In addition, there was absence of the right portal vein and the left intrahepatic branch except for the presence of left portal vein only within the porta hepatis. These findings led to a diagnosis of CAPV complicated hepatic tumors. Careful monitoring of these hepatic tumors is ongoing due to the possibility of malignant transformation.     

Leiomyosarcoma of the middle segment of the inferior vena cava: tactical problems raised by renal and caval revascularisation

INTRODUCTION: Leiomyosarcoma of the inferior vena cava is mesenchymal tumor accounting for 95% of primary tumors of the vena cava. Characteristic features include late invasion of adjacent structures and metastases, and delayed diagnosis. OBSERVATION: We report a case of inferior vena cava (IVC) leiomyosarcoma (LMS) found in a 53 year-old man who complained of abdominal pain. Morphologic exams found a very large polycyclic mass in the inferior vena cava involving the middle segment of the vena cava extending from the renal veins to the hepatic veins. An "en bloc" resection of the tumor was achieved. Caval outflow was restored using a ring-reinforced PTFE tube graft, the left renal vein was ligated and not re-implanted, the right renal vein was implanted in a lumbar sub-renal vein using a short prosthesis. Pathological examination documented a grade II leiomyosarcoma of the inferior vena cava and the patient was given adjuvant chemotherapy (anthracycline). One year later, there was no local or regional relapse. COMMENT: We emphasize the importance of restoring caval outflow which provides effective results when used with a ring-reinforced polytetrafluoroethylene (PTFE) prosthesis. Furthermore, the importance of restoring right renal outflow is highlighted because ligature of the renal vein can lead to renal ischemia and nephrectomy which should only be performed in specific cases. The tactical problems of renal and caval revascularisation, including the place of prosthetic replacement, are discussed.     

Combined resection of the inferior vena cava for hepato-biliary and pancreatic malignancies

Seven cases of hepato-biliary and pancreatic malignancies that underwent partial resection of the inferior vena cava) were reviewed. Histological findings of inferior venca cava involvement were direct invasion in 5 cases, tumor thrombus in 1 case, and adhesion in 1 case. Correct preoperative diagnosis of inferior vena cava involvement was made in only 2 cases. A retrospective study on enhanced CT revealed that irregular deformity of the inferior vena cava had suggested inferior vena cava involvement. Total occlusion of the inferior vena cava was employed temporarily for inferior vena cava resection in 3 cases. A saphenous vein graft was used for reconstruction in 2 cases. Complications due to inferior vena cava resection are, as yet, unknown. One patient is alive, without recurrence, 24 months after the operation. One case underwent re-resection of liver metastasis, and is alive 17 months after the operation. Although advanced hepato-biliary and pancreatic malignancies involving inferior vena cava have been regarded as having a poor prognosis, an aggressive surgical approach may be applicable in some cases.     

Clinical features and imaging diagnosis of biliary cystadenocarcinoma of the liver

Biliary cystadenocarcinoma of the liver is a relatively rare disease. Herein, we reported a case of biliary cystadenocarcinoma with a review of the literature. A 71-year-old female was admitted with the chief complaint of epigastralgia. The imaging studies revealed a biliary cystadenocarcinoma in the left hepatic lobe with suspicion of direct invasion to the left and middle hepatic veins and inferior vena cava. However, there was no direct invasion of the tumor to these veins in operation findings, and an extended left hepatic resection was performed without resection of inferior vena cava. The tumor was histologically diagnosed as biliary cystadenocarcinoma of the liver. Diagnosis of biliary cystadenocarcinoma is usually difficult preoperatively, however, a diagnosis was possible with the use of imaging studies. It was suggested that this tumor originated from a benign cystadenoma because of the existence of a transitional zone between normal cells and atypical cells in the cystic wall. Systematic hepatectomy was recommended as the initial treatment in consideration of the features of cystadenocarcinoma.     

“En bloc ” caudate lobe and inferior vena cava resection following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal and liver metastasis of colorectal cancer

There are diverse protocols to manage patients with recurrent disease after primary cytoreductive surgery(CRS) with hyperthermic intraperitoneal chemotherapy(HIPEC) for peritoneal carcinomatosis. We describe a case of metachronous liver metastasis after CRS and HIPEC for colorectal cancer, successfully treated with a selective metastectomy and partial graft of the inferior vena cava. A 35-year-old female presented with a large tumour in the cecum and consequent colonic stenosis. After an emergency right colectomy, the patient received adjuvant chemotherapy. One year later she was diagnosed with peritoneal carcinomatosis, and it was decided to carry out a CRS/HIPEC. After 2 years of total remission, an isolated metachronous liver metastasis was detected by magnetic resonance imaging surveillance. The patient underwent a third procedure including a caudate lobe and partial inferior vena cava resection with a prosthetic graft interposition, achieving an R0 situation. The postoperative course was uneventful and the patient was discharged on postoperative day 17 after the liver resection. At 18-mo follow-up after the liver resection the patient remained free of recurrence. In selected patients, the option of re-operation due to recurrent disease should be discussed. Even liver resection of a metachronous metastasis and an extended vascular resection are acceptable after CRS/HIPEC and can be considered as a potential treatment option to remove all macroscopic lesions.     

“En bloc” caudate lobe and inferior vena cava resection following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal and liver metastasis of colorectal cancer

There are diverse protocols to manage patients with recurrent disease after primary cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis. We describe a case of metachronous liver metastasis after CRS and HIPEC for colorectal cancer, successfully treated with a selective metastectomy and partial graft of the inferior vena cava. A 35-year-old female presented with a large tumour in the cecum and consequent colonic stenosis. After an emergency right colectomy, the patient received adjuvant chemotherapy. One year later she was diagnosed with peritoneal carcinomatosis, and it was decided to carry out a CRS/HIPEC. After 2 years of total remission, an isolated metachronous liver metastasis was detected by magnetic resonance imaging surveillance. The patient underwent a third procedure including a caudate lobe and partial inferior vena cava resection with a prosthetic graft interposition, achieving an R0 situation. The postoperative course was uneventful and the patient was discharged on postoperative day 17 after the liver resection. At 18-mo follow-up after the liver resection the patient remained free of recurrence. In selected patients, the option of re-operation due to recurrent disease should be discussed. Even liver resection of a metachronous metastasis and an extended vascular resection are acceptable after CRS/HIPEC and can be considered as a potential treatment option to remove all macroscopic lesions.     

Polysplenia syndrome with congenital agenesis of dorsal pancreas presenting as acute pancreatitis and the role of endoscopic ultrasonography in its diagnosis

A 49-year-old female was admitted to our hospital for acute pancreatitis. The abdomen CT scan incidentally showed midline liver with hepatomegaly, centrally located gallbladder, pancreas truncation, right sided small bowel, left sided large bowel, interruption of the inferior vena cava with azygos continuation, preduodenal portal vein, and multiple spleens in the left upper quadrant. In MRCP, the head of pancreas was enlarged and short main pancreatic duct without accessory duct was showed. EUS revealed enlarged ventral pancreas with a main pancreatic duct of normal caliber, absence of the accessory pancreatic duct and the dorsal pancreas. She was diagnosed as polysplenia syndrome with agenesis of dorsal pancreas. It is a rare congenital anomaly frequently associated with various visceral anomalies including multiple spleens, impaired visceral lateralization, congenital heart diseases, gastrointestinal abnormalities and azygos continuation of the inferior vena cava. We report a case of polysplenia syndrome with agenesis of dorsal pancreas presenting acute pancreatitis.     

Malignant fibrous histiocytoma of the liver

We report on a 43-year-old man with a primary sarcoma of the liver. The patient was admitted to the hospital for evaluation of dyspnea, abdominal pain in the right upper quadrant, diarrhea, and fever. Physical examination revealed hepatomegaly. Increased laboratory values were found for gamma-GT, LDH, CA 125, and NSE, but not for aspartate and alanine aminotransferase. Computed tomography presented a tumor in the right lobe of the liver. Venous cavography revealed a caval tumor thrombus reaching up to the right atrium. Major liver resection combined with replacement of the vena cava inferior was proposed, but before operation the patient complained about shortness of breath. Spontaneous fragmentation of the tumor thrombus with consecutive embolization of the lungs was suspected. Despite lysis therapy the patient died because of right ventricular failure. Autopsy revealed a tumor measuring 8 cm in diameter, which was located in the right lobe of the liver and invaded the inferior vena cava. Because of multiple tumor aggregates seen in the left and right main pulmonary arteries acute tumor embolization of the lungs was regarded as cause of death. Histologically the tumor was composed of bizarre giant cells surrounded by irregular spindle cells. The positive immunoreactivity pattern of the tumor cells for vimentin, lysozym, and CD68 justified the diagnosis of a malignant fibrous histocytoma (MFH) of the liver.     

The Role of Myocardial Contrast Echocardiography to Assess the Origin of a Mass in Right Cardiac Cavities

We report the case of a patient with hepatocellular carcinoma who was admitted to our hospital with fatigue and edema of lower extremities. Transthoracic echocardiographic examination revealed a mobile echogenic cavoatrial mass that infiltrated the inferior vena cava and extended along the vessel protruding into the right cardiac cavities. The differential diagnosis included a tumor mass originating from the liver and subsequently infiltrating the inferior vena cava and extending into the right cardiac cavities or a large thrombus formed on the tumor mass that infiltrated the inferior vena cava.