Retrocaval liver lifting maneuver and modifications of total hepatic vascular exclusion for liver tumor resection

AIM: To evaluate the efficacy of technical modifications of total hepatic vascular exclusion(THVE) for hepatectomy involving inferior vena cava(IVC).METHODS: Of 301 patients who underwent hepatectomy during the immediate previous 5-year period, 8(2.7%) required THVE or modified methods of IVC cross-clamping for resection of liver tumors with massive involvement of the IVC. Seven of the patients had diagnosis of colorectal liver metastases and 1 had diagnosis of hepatocellular carcinoma. All tumors involved the IVC, and THVE was unavoidable for combined resection of the IVC in all 8 of the patients. Technical modifications of THVE were applied to minimize the extent and duration of vascular occlusion, thereby reducing the risk of damage.RESULTS: Broad dissection of the space behind the IVC coupled with lifting up of the liver from the retrocaval space was effective for controlling bleeding around the IVC before and during THVE. The procedures facilitate modification of the positioning of the cranial IVC cross-clamp. Switching the cranial IVC cross-clamp from supra- to retrohepatic IVC or to the confluence of hepatic vein decreased duration of the THVE while restoring hepatic blood flow or systemic circulation via the IVC. Oblique cranial IVC cross-clamping avoided ischemia of the remnant hemi-liver. With these technicalmodifications, the mean duration of THVE was 13.4 ± 8.4 min, which was extremely shorter than that previously reported in the literature. Recovery of liver function was smooth and uneventful for all 8 patients. There was no case of mortality, re-operation, or severe complication(i.e., Clavien-Dindo grade of Ⅲ or more).CONCLUSION: The retrocaval liver lifting maneuver and modifications of cranial cross-clamping were useful for minimizing duration of THVE.     

Autologous transfusion with modified total hepatic vascular exclusion for extracapsular resection of giant hepatic cavernous hemangioma

Introduction Hemangioma is the most common benign tumor affecting the liver. Although the majority of hepatic hemangiomas never cause symptoms, some may do so because of capsule tension, local necrosis, or compression of adjacent tissues or organs, and even severe complications such as spontaneous rupture, abscess, or consumptive coagulopathy (Kasabach-Merrit syndrome).[1] Inter- ventional therapy for hepatic hemangioma is dangerous,[2] so surgery is still the most effective treatment. Howeve…     

Total vascular exclusion technique for resection of hepatocellular carcinoma

AIM: To improve the low resection rate, poor prognosis and to control the massive hemorrhage during operation, total vascular exclusion (TVE) technique was used in hepatectomies of advanced and complicated hepatocellular carcinomas (HCCs). METHODS: Five hundred and thirty patients with HCCs were admitted in our hospital. They were divided into TVE technique group (group A: n=78), Pringle maneuver method group (group B: n=176) and unresectable group (group C: n=276). The clinical, operative, pathological parameters and outcome of the patients were statistically evaluated. RESULTS: Group A had a significantly higher resection rate than group B (accounting for 47.92% and 33.21% respectively). There was no significant difference in blood loss, blood transfusion and perioperative mortality between groups A and B. Both groups had the similar median disease free survival time (14.6 vs 16.3 months) and 1 year survival rate (92.9% vs 95.5%). The TVE group had a medial survival time of 40.5 months and its 5-year survival rate was 34.6%. CONCLUSION: As compared with Pringle maneuver method, the total vascular exclusion is a safe and effective technique to increase the total resection rate of advanced and complicated HCCs.     

Laparoscopic liver resection facilitates salvage liver transplantation for hepatocellular carcinoma

Background/Purpose

In patients with hepatocellular carcinoma (HCC), a previous liver resection (LR) may compromise subsequent liver transplantation (LT) by creating adhesions and increasing surgical difficulty. Initial laparoscopic LR (LLR) may reduce such technical consequences, but its effect on subsequent LT has not been reported. We report the operative results of LT after laparoscopic or open liver resection (OLR).

Methods

Twenty-four LT were performed, 12 following prior LLR and 12 following prior OLR. The LT was performed using preservation of the inferior vein cava. Indication for the LT was recurrent HCC in 19 cases (salvage LT), while five patients were listed for LT and underwent resection as a neoadjuvant procedure (bridge resection).

Results

In the LLR group, absence of adhesions was associated with straightforward access to the liver in all cases. In the OLR group, 11 patients required long and hemorrhagic dissection. Median durations of the hepatectomy phase and whole LT were 2.5 and 6.2 h, and 4.5 and 8.3 h in the LLR and OLR groups, respectively (P < 0.05). Median blood loss was 1200 ml and 2300 ml in the LLR and OLR groups, respectively (P < 0.05). Median transfusions of hepatectomy phase and whole LT were 0 and 3 U, and 2 and 6 U, respectively (P < 0.05). There were no postoperative deaths.

Conclusions

In our study, LLR facilitated the LT procedure as compared with OLR in terms of reduced operative time, blood loss and transfusion requirements. We conclude that LLR should be preferred over OLR when feasible in potential transplant candidates.     

Left-hand-assisted laparoscopic resection of hepatocellular carcinoma in an accessory liver

We report a left‐hand‐assisted laparoscopic resection of hepatocellular carcinoma that developed in an accessory liver in a 47‐year‐old man. Preoperative assessment of the location of the tumor and the feeder vessels by combined selective angiography and computed tomography studies predicted the feasibility of laparoscopic procedures for complete removal of the tumor. In an attempt to avoid direct contact of the tumor capsule with rigid instruments during the operation, left‐hand‐assisted procedures were attempted. The encapsulated mass, 6 × 5 × 3 cm in size, was located on the posterior side of the left diaphragm, and a thin stalk between the tumor and the margin of the left lateral segment of the liver proper was recognized. Hand‐assisted procedures ensured the complete mobilization of the lesion with an adequate margin, without any unexpected capsular tear. Left‐hand‐assisted laparoscopic procedures would be feasible for the easy and safe resection of localized hepatocellular carcinoma developing in an accessory liver.     

Successful management and technical aspects of major liver resection in children: A retrospective cohort study

Optimal treatment of patients with various types of liver tumors or certain liver diseases frequently demands major liver resection, which remains a clinical challenge especially in children.Eighty seven consecutive pediatric liver resections including 51 (59%) major resections (resection of 3 or more hepatic segments) and 36 (41%) minor resections (resection of 1 or 2 segments) were analyzed. All patients were treated between January 2010 and March 2018. Perioperative outcomes were compared between major and minor hepatic resections.The male to female ratio was 1.72:1. The median age at operation was 20 months (range, 0.33–150 months). There was no significant difference in demographics including age, weight, ASA class, and underlying pathology. The surgical management included functional assessment of the future liver remnant, critical perioperative management, enhanced understanding of hepatic segmental anatomy, and bleeding control, as well as refined surgical techniques. The median estimated blood loss was 40 ml in the minor liver resection group, and 90 ml in major liver resection group (P < .001). Children undergoing major liver resection had a significantly longer median operative time (80 vs 140 minutes), anesthesia time (140 vs 205 minutes), as well as higher median intraoperative total fluid input (255 vs 450 ml) (P < .001 for all). Fourteen (16.1%) patients had postoperative complications. By Clavien-Dindo classification, there were 8 grade I, 4 grade II, and 2 grade III-a complications. There were no significant differences in complication rates between groups (P = .902). Time to clear liquid diet (P = .381) and general diet (P = .473) was not significantly different. There was no difference in hospital length of stay (7 vs 7 days, P = .450). There were no 90-day readmissions or mortalities.Major liver resection in children is not associated with an increased incidence of postoperative complications or prolonged postoperative hospital stay compared to minor liver resection. Techniques employed in this study offered good perioperative outcomes for children undergoing major liver resections.     

Anatomic segmental resection compared to major hepatectomy in the treatment of liver neoplasms

Background. Familiarity with liver anatomy and refinements in operative technique have led to interest in liver conservation when dealing with hepatic tumors. There is thought to be less morbidity, less blood loss (EBL), a shorter hospital stay (LOS), and no penalty for long-term survival with segmental hepatectomy.Methods. One hundred ninety-six patients who underwent segmental (SEG group) (N=70) or major (MAJOR group) (N=126) hepatectomy for liver neoplasms were retrospectively reviewed. Clinical parameters of mortality, morbidity, EBL, LOS, and actuarial survival in patients with colorectal metastases were examined.Results. There were no differences in age or gender between the SEG and MAJOR groups. There were no deaths among 64 non-cirrhotic patients in the SEG group and 4 deaths (3.2%) among 124 non-cirrhotic patients in the MAJOR group (p=0.19). There were 4 postoperative complications in the SEG group (5.6%) and 22 in the MAJOR group (17.3%) (p<0.05).The EBL for the SEG group was 912±842 ml compared to 3675±3110 ml in the MAJOR group (p<0.001).The hospital LOS for the SEG group was 9.4±6.4 days and for the MAJOR group 10.2±5.9 days (p=0.32). Life table analysis of survival for resection of colorectal metastases showed two-year patient survival of 40% in the SEG group (N=17) and 45% for the MAJOR group (N=46).Conclusion. Segmental resections were associated with less EBL and fewer postoperative complications. There was a trend towards fewer deaths in non-cirrhotic patients, and no apparent penalty for a smaller hepatic resection in long-term survival. While sometimes technically more challenging, segmental resections are preferable when feasible and should be utilized in efforts to conserve liver parenchyma.     

Risk factors for early death after liver resection in patients with solitary hepatocellular carcinoma

Background/Purpose

Although most patients who receive hepatectomy for a solitary hepatocellular carcinoma (HCC) have a relatively fair result, some have a poor prognosis. The aim of this study was to evaluate the risk factors for early death after hepatectomy in patients with a solitary HCC.

Methods

Eligible patients (n = 110) who had undergone hepatectomy for solitary HCC between 1990 and 2002 and were able to be followed up for more than 2 years after the hepatectomy were divided into two groups, those who died of cancer recurrence within 2 years (early-death group; n = 18) and those who survived for more than 2 years after the surgery (survival group; n = 92). Risk factors for early death after liver resection were evaluated by univariate and multivariate analyses.

Results

The gross tumor classification, tumor diameter, macroscopic portal vein invasion, microscopic growth pattern, microscopic vascular invasion (MVI), and the width of the surgical margin were significant (P < 0.05) factors by univariate analysis. Multivariate analysis showed that the presence of MVI was an independent and significant risk factor for early death of recurrence.

Conclusions

Among patients with solitary HCC, the presence of MVI indicates a poor prognosis. These patients need adjuvant chemotherapy in the early period after hepatectomy.     

规则性肝切除术治疗原发性肝癌的分析

目的:随机对照观察规则性肝切除术治疗原发性肝癌的安全性以及临床疗效,探讨治疗肝癌合理的手术方式.方法:将38例肝切除术治疗原发性肝癌的患者随机分为2组:规则性肝切除术15例.非规则性肝切除术23例,对两组病例的手术和随访情况进行分析评价.结果:两组均无手术死亡,术中出血、并发症发生率、住院时间无显著差异.规则性肝切除标本切缘满意率(大于2cm)较高,术后近期复发率显著降低,一年无瘤生存率高于非规则性肝切除.结论:规则性肝切除是治疗原发性肝癌安全有效的术式,对有适应证的病例应尽可能采用此种手术方式,有望获得较好的疗效.     

Treatment for hepatocellular carcinoma associated with tumor embolus in the inferior vena cava

Hepatic resection and removal of the tumor embolus was performed in six patients with hepatocellular carcinoma associated with tumor embolus in the inferior vena cava, without distant metastasis. Hepatic resection was performed in five patients under total hepatic vascular exclusion (THVE) with veno-venous bypass, using a centrifugal force pump and in one patient, under simple THVE without the bypass. In one patient, partial resection of segment VIII was performed, in one, a central bi-segmentectomy, and in four, right hepatic lobectomies were performed. Surgery was safely performed in all the 5 patients under THVE using the centrifugal force pump. One patient who underwent partial hepatic resection under the simple THVE, suffered cardiac arrest during surgery, but resuscitation was successful. Three patients died of reccurence within 1 year. The other three patients survived for 10 months, 2 years and 10 months, and 3 years and 10 months, respectively, after surgery. There were recurrences in the first two, patients, in both, treated by transcatheter arterial embolization, and to date, the third patient is disease-free. Hepatic resection was safely performed in patients with hepatocellular carcinoma associated with tumor embolus in the inferior vena cava, under conditions of THVE using the centrifugal force pump. Prolonged survival can be anticipated, with favorable liver function, in those patients in whom most of the lesion is resected.     

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

AIM: To conduct a meta-analysis to determine the safety and efficacy of laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC).METHODS: PubMed (Medline), EMBASE and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library were searched systematically to identify relevant comparative studies reporting outcomes for both LLR and OLR for HCC between January 1992 and February 2012. Two authors independently assessed the trials for inclusion and extracted the data. Meta-analysis was performed using Review Manager Version 5.0 software (The Cochrane Collaboration, Oxford, United Kingdom). Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either fixed effects (Mantel-Haenszel method) or random effects models (DerSimonian and Laird method). Evaluated endpoints were operative outcomes (operation time, intraoperative blood loss, blood transfusion requirement), postoperative outcomes (liver failure, cirrhotic decompensation/ascites, bile leakage, postoperative bleeding, pulmonary complications, intraabdominal abscess, mortality, hospital stay and oncologic outcomes (positive resection margins and tumor recurrence).RESULTS: Fifteen eligible non-randomized studies were identified, out of which, 9 high-quality studies involving 550 patients were included, with 234 patients in the LLR group and 316 patients in the OLR group. LLR was associated with significantly lower intraoperative blood loss, based on six studies with 333 patients [WMD: -129.48 mL; 95%CI: -224.76-(-34.21) mL; P = 0.008]. Seven studies involving 416 patients were included to assess blood transfusion requirement between the two groups. The LLR group had lower blood transfusion requirement (OR: 0.49; 95%CI: 0.26-0.91; P = 0.02). While analyzing hospital stay, six studies with 333 patients were included. Patients in the LLR group were found to have shorter hospital stay [WMD: -3.19 d; 95%CI: -4.09-(-2.28) d; P < 0.00001] than their OLR counterpart. Seven studies including 416 patients were pooled together to estimate the odds of developing postoperative ascites in the patient groups. The LLR group appeared to have a lower incidence of postoperative ascites (OR: 0.32; 95%CI: 0.16-0.61; P = 0.0006) as compared with OLR patients. Similarly, fewer patients had liver failure in the LLR group than in the OLR group (OR: 0.15; 95%CI: 0.02-0.95; P = 0.04). However, no significant differences were found between the two approaches with regards to operation time [WMD: 4.69 min; 95%CI: -22.62-32 min; P = 0.74], bile leakage (OR: 0.55; 95%CI: 0.10-3.12; P = 0.50), postoperative bleeding (OR: 0.54; 95%CI: 0.20-1.45; P = 0.22), pulmonary complications (OR: 0.43; 95%CI: 0.18-1.04; P = 0.06), intra-abdominal abscesses (OR: 0.21; 95%CI: 0.01-4.53; P = 0.32), mortality (OR: 0.46; 95%CI: 0.14-1.51; P = 0.20), presence of positive resection margins (OR: 0.59; 95%CI: 0.21-1.62; P = 0.31) and tumor recurrence (OR: 0.95; 95%CI: 0.62-1.46; P = 0.81).CONCLUSION: LLR appears to be a safe and feasible option for resection of HCC in selected patients based on current evidence. However, further appropriately designed randomized controlled trials should be undertaken to ascertain these findings.     

Current status of hepatic resection for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common tumors worldwide. For this disease, a variety of therapeutic measures have been applied, including hepatic resections, total hepatectomy followed by allografting, transarterial chemoembolization, and percutaneous tumor ablative therapy by ethanol, microwave coagulation, and radiofrequency ablation. This article focuses on the current status of hepatic resections for HCC.     

肝切除术后胸腔积液的成因及处理

目的探讨肝切除术后常见的并发症胸腔积液的成因及处理方法。方法回顾分析连续９２例肝细胞癌行肝切除术的病例。术后发生胸腔积液３３例（胸腔积液组），其余５９例为非胸腔积液组。患者年龄、术前白蛋白水平、肝门阻断时间、肿瘤大小、肿瘤部位、门静脉癌栓、腹水、膈下积液、肝硬变等因素对胸腔积液形成的影响进行了分析。结果肿瘤部位、肝门阻断时间、肝硬变、膈下积液显著影响胸腔积液的形成。结论肝切除术后胸腔积液的发生与多种因素有关，缩短肝门阻断时间，减少膈下积液的发生将有助于降低这一并发症的发生。根据患者耐受程度，可相应选择控制体温、胸腔穿刺抽液、胸腔闭式引流等治疗方法。     

Hepatic resection for primary giant leiomyoma of the liver

Background

Smooth muscle tumours are common in the genito-urinary and gastro-intestinal tracts, but primary leiomyoma of the liver is extremely rare. Only a few cases have been reported to date.

Case outline

We report a case of giant leiomyoma of the liver in a 67-year-old woman that was treated by an extended right hepatectomy. There was no evidence of leiomyoma elsewhere in the abdomen (including the uterus).

Discussion

This appears to be the largest hepatic leiomyoma reported in the literature.     

Laparoscopic liver resection for benign and malignant liver tumors

BACKGROUND:Laparoscopic liver resection is one of the most complex procedures in hepatobiliary surgery.In the last two decades,laparoscopic liver surgery has emerged as an option at major academic institutions.The purpose of this study is to describe the initial experience of minimally invasive liver resections at a non-academic institution. METHODS:We retrospectively reviewed medical records of patients undergoing laparoscopic liver resections between June 2006 and December 2009 at our center.Indications, ...