A prospective randomized controlled trial to compare two methods of selective hepatic vascular exclusion in partial hepatectomy

Background and aim

Selective hepatic vascular exclusion (SHVE) has not been widely used because of difficulty in extrahepatic isolation of hepatic veins. This study aims to compare the results of SHVE using tourniquets or Satinsky clamps on major hepatic veins in partial hepatectomy for liver tumors involving the roots of hepatic veins.

Methods

Between June 2008 and March 2012, a randomized controlled trial was performed on patients undergoing liver resection to compare selective hepatic vascular exclusion using tourniquets or Satinsky clamps in partial hepatectomy. In the tourniquet group, the hepatic veins were completely isolated and occluded with tourniquets. In the Satinsky clamp group, the hepatic veins were dissected on the anterior and side walls only and they were clamped directly by Satinsky clamps.

Results

The time for dissecting hepatic veins was significantly shorter in the Satinsky clamp group (7.5 ± 6.6 min vs 21.3 ± 7.4 min) than the tourniquet group. In the tourniquet group, 5 hepatic veins could not be completely isolated and encircled. In 4 additional patients the hepatic vein was slightly torn during dissection. These 9 patients received successful occlusion using Satinsky clamps. In the Satinsky group, all occlusion of the hepatic vein was successful. There was a significant difference in the success rate in hepatic vein occlusion using the Satinsky and the tourniquet groups 60/60 vs 51/60, P = 0.0018.

Conclusions

Both techniques of hepatic vein occlusion were safe and efficacious. As the use of Satinsky clamps is safer, easier and took less time, it is recommended.     

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.     

Laparoscopic radiofrequency ablation of the liver in proximity to major vasculature: effect of the Pringle maneuver

BACKGROUND AND OBJECTIVES: The Pringle maneuver has been shown to increase ablation size during radiofrequency ablation (RFA). Efficacy of laparoscopic Pringle in proximity to major vasculature has not been well described. Laparoscopic RFA was performed in proximity to major hepatic vessels to examine effects of the Pringle on ablation size and vascular damage. METHODS: Laparoscopic RFA was performed in 10 pigs. Each underwent ablation of a peripheral site, and sites adjacent to the portal and hepatic veins. Ultrasound was used to position the RFA adjacent to vascular structures. US flow characteristics verified occlusion of blood flow. Five pigs underwent laparoscopic RFA with Pringle and five underwent laparoscopic RFA alone. Animals were then sacrificed for gross and microscopic evaluation. RESULTS: Peripheral, hepatic, and portal vein ablations showed no significant differences in volume between non-Pringle and Pringle lesions, though the median ablation volume for the peripheral site in the Pringle group was approximately twice that of the non-Pringle group. Pringle group overall median time to target temperature was significantly shorter (P = 0.047). Histologic examination revealed no evidence of endothelial damage or thermal-induced intravascular thrombosis of the hepatic or portal veins. CONCLUSIONS: Laparoscopic RFA with Pringle in proximity to major vascular structures does not significantly increase ablation size, or cause acute vascular damage. Further studies are necessary to determine the utility of the Pringle in proximity to major intrahepatic blood vessels.     

Relationship between the shape and size of radiofrequency induced thermal lesions and hepatic vascularization.

AIMS AND BACKGROUND: The aim of this study was to evaluate the relationship between hepatic vascularisation and the final size and shape of radiofrequency (RF) induced thermal lesions. METHODS: Series of four RF thermal lesions were created in explanted calf livers and in pig livers maintaining the following experimental conditions throughout the procedure: normal hepatic perfusion, occlusion of the hepatic artery, occlusion of the portal vein, occlusion of both hepatic artery and portal vein (Pringle maneuver) and subtotal occlusion of the hepatic veins. A 14G expandable needle electrode was used to make the thermal lesions. Each lesion was created applying predetermined temperatures ranging between 95 and 115 degrees C and an exposure time of 20 minutes. RESULTS: Occlusion of the hepatic artery during the RF procedure resulted in moderate and not significant increases in thermal lesion diameter compared with those obtained in normally perfused liver (3.0 +/- 0.4 cm vs 3.0 +/- 0.2 cm), while occlusion of the portal vein resulted in larger lesion diameters (3.5 +/- 0.3 cm). In both these cases the diameters of the thermal lesions were smaller than those obtained in explanted calf liver (4.0 +/- 0.3 cm) and their shape showed peripheral irregularities. Thermal lesions larger than those seen in normally perfused liver and equaling those observed in explanted calf liver were created both during the Pringle maneuver (4.0 +/- 0.2 cm) and after subtotal occlusion of the hepatic veins (4.0 +/- 0.3 cm). In both these cases the thermal lesions were regular in shape. CONCLUSIONS: Occlusion of the blood flow during the RF procedure avoids heat loss by convection, resulting in the creation of larger thermal lesions than those obtained in normally vascularized liver using the same electrode, temperatures and exposure time. This technique could therefore be employed in humans to destroy large hepatic tumor nodules.     

Liver resection using bipolar InLine multichannel radiofrequency device: Impact on intra- and peri-operative outcomes

Aims

Liver resection is indicated for several primary and secondary liver lesions. We follow up our earlier experience with the use of InLine Multichannel Radiofrequency Device (ILMRD, Resect Medical Inc., Fremont, CA) a device that produces coagulative necrosis along the transection plane.

Methods

The records of 68 consecutive patients who underwent liver resection for primary and metastatic liver tumors from August 2000 to December 2008 were reviewed. Data analyzed include demographic data as well as complexity of liver resection, intra-operative blood loss, use of portal triad clamping and transfusion of blood. Postoperative outcomes measured were morbidity, hospital and ICU length of stay.

Results

The median estimated blood loss was 150 mL in the ILMRD group compared to 400 mL in the non-ILMRD group (p < 0.0001). Median length of stay was decreased in the ILMRD group by a day (7 vs. 8 p < 0.003). There was a significant decrease in frequency of parenchymal clamp time (57% vs 84%, p < 0.001) and median total portal triad clamp time (2.5 vs 30 min p < 0.0001). We also noted a significant decrease in the median portal triad clamp time (0 vs 25 min, p < 0.001) used during the parenchymal transection phase. Furthermore, use of the ILMRD device allowed us to perform more complex hepatic resections.

Conclusion

Use of ILMRD to perform radiofrequency-assisted hepatic resection was associated with a significant decrease in intra-operative blood loss and earlier discharge from the hospital despite increasing complexity of resections and decreased use of portal triad clamping.     

Trisectionectomy for large hepatocellular carcinoma using the liver hanging maneuver

Background/Purpose

Large liver tumors often expand and severely compress intrahepatic vessels. In cases of the trisectionectomy for such tumors, however, it is difficult to adequately expose the transection planes. The liver hanging maneuver (LHM) is a useful technique for hemihepatectomy and an adequate transection plane might be also required in trisectionectomy.

Methods

LHM procedure is basically followed by the Belghiti's method. A nasogastric tube was used for hanging. At the hepatic hilum, the tube was placed between the liver and Glisson's pedicle.

Results

We report here the application of LHM for right and left trisectionectomy in patients with a large hepatoma in two cases. In case of a right trisectionectomy for a large tumor compressing the umbilical Glisson's pedicle, an adequate transection plane was obtained using the LHM because the resected and remnant livers rotated to the other side upon lifting the tube during transection. In case of a left trisectionectomy for a large hepatic tumor compressing the right hepatic vein, an adequate transection plane along the right hepatic vein was obtained using LHM as well.

Conclusions

LHM is a useful surgical application for right and left trisectionectomy in patients with large liver tumors compressing the cut plane.     

Radiofrequency assisted liver resection: analysis of 604 consecutive cases

Background

Intraoperative blood loss is an important factor contributing to morbidity and mortality in liver surgery. To address this we developed a bipolar radiofrequency (RF) device, the Habib 4X, used specifically for hepatic parenchymal transection. The aim of this study was to prospectively assess the peri-operative data using this technique.

Methods

Between 2001 and 2010, 604 consecutive patients underwent liver resections with the RF assisted technique. Clinico-pathological and outcome data were collected and analysed.

Results

There were 206 major and 398 minor hepatectomies. Median intraoperative blood loss was 155 (range 0–4300) ml, with a 12.6% rate of transfusion. There were 142 patients (23.5%) with postoperative complications; none had bleeding from the resection margin. Only one patient developed liver failure and the mortality rate was 1.8%.

Conclusions

RF assisted liver resection allows major and minor hepatectomies to be performed with minimal blood loss, low blood transfusion requirements, and reduced mortality and morbidity rates.     

不同肝血流阻断方法对可手术小肝癌预后的影响

目的 比较可手术小肝癌选择性适时半肝血流阻断法与肝十二指肠韧带阻断法（Pringle法）对患者中长期生存的影响。方法 根据肝血流阻断不同方式,将我院腹部外科222例小肝癌手术患者分为无肝门阻断、选择性适时半肝血流阻断与Pringle法3组,对以上患者进行随访,收集生存资料进行分析比较。结果 选择性适时半肝血流阻断组与无肝门阻断和Pringle法组患者之间中位生存时间差异有统计学意义（P值分别为0.02、0.04）。无肝门阻断、选择性适时半肝血流阻断和Pringle法组患者3年生存率分别为81.3%、93.3%和76.0%,三者间差异有统计学意义（P=0.008）;5年生存率分别为70.6%、90.8%和50.7%,三者间差异有统计学意义（P<0.001）。选择性适时半肝血流阻断组3年生存率与5年生存率均优于其他两组。结论 在小肝癌可手术患者中应用选择性适时半肝血流阻断较Pringle法能显著延长患者的生存时间,提高患者生存率。     

The ALPPS procedure for hepatocellular carcinoma

Background

The main limiting factor to major hepatic resections is the amount of the future liver remnant (FLR). Associating Liver Partition with Portal Vein Ligation for Staged Hepatectomy (ALPPS) is a procedure which induces a rapid hypertrophy of the FLR in patients with non-resectable liver tumours.

Methods

ALPPS is a surgical technique of in-situ splitting of the liver along the main portal scissura or the right side of the falciform ligament, in association with portal vein ligation in order to induce a rapid hypertrophy of the left FLR.

Results

The median FLR volume increase was 18.7% within one week after the first step and 38.6% after the second step. At the first step the median operating time was 300 min, blood transfusions were not required in any case, median blood loss was 150 cc. At the second step median operating time was 180 min, median blood loss was 50 cc, none of the patients required intra-operative blood. All patients are alive at a median follow up of 9 months.

Conclusions

This novel strategy seems to be feasible even in the context of a cirrhotic liver, and demonstrates the capacity to reach a sufficient FLR within a shorter interval of time.     

Prolonged portal triad clamping during liver surgery for colorectal liver metastases is associated with decreased time to hepatic tumour recurrence

Aims

The aim of this study was to evaluate the oncological outcome of portal triad clamping during hepatectomy in colorectal cancer patients.

Methods

160 patients with colorectal liver metastases underwent a partial hepatectomy with curative intent. Data were collected in a prospective database and were retrospectively analyzed for time to liver recurrence (TTLiR) and time to overall recurrence (TTR). The prognostic significance of portal triad clamping of any type and severe ischemia due to prolonged portal triad clamping was determined by Cox regression models.

Results

TTLiR was reduced after clamping of any type, although not statistically significant (p = 0.061). Severe ischemia due to prolonged portal triad clamping significantly decreased TTLiR (p = 0.022), but not TTR. Furthermore, severe ischemia independently predicted TTLiR in a multivariable analysis (p = 0.038).

Conclusions

Severe ischemia due to prolonged portal triad clamping during hepatic resection for colorectal liver metastases appears to be associated with decreased TTLiR. Further research remains necessary to determine the causative effect of prolonged vascular clamping on liver tumour recurrence.     

Prognostic influence of the liver hanging maneuver for patients with hepatobiliary malignancies who underwent hepatic resections

Background

Prognostic influences of hepatic transection by an anterior approach using the liver hanging maneuver (LHM) has not been fully clarified.

Methods

We examined 233 patients who underwent major hepatectomy with the LHM (n = 75; hepatocellular carcinoma (HCC) in 35, colorectal liver metastasis (CLM) in 10, intrahepatic cholangiocarcinoma (ICC) in 14 and perihilar bile duct carcinoma (BDC) in 16) or without it (n = 158; HCC in 78, CLM in 21, ICC in 31 and BDC in 28).

Results

In HCC patients, cancer-positive margin rate, blood loss, transection time and prevalence of posthepatectomy ascites in the LHM group were significantly lower than those in the non-LHM group (p < 0.05). In CLM, transection time in the LHM group was significantly lower than that in the non-LHM group (p < 0.05). In BDC patients, amount of blood loss, transection time and prevalence of ascites in the LHM group were significantly lower than those in the non-LHM group (p < 0.05). In CLM patients, tumor recurrence rate in the non-LHM group was significantly higher than that in the LHM group and disease-free survival in the LHM group was significantly better than that in the non-LHM group in CLM patients and, however, this difference was not observed in a large CLM exceeding 5 cm. However, significant differences of posthepatectomy disease-free and overall survivals were not observed in HCC, ICC and BDC patients.

Conclusions

Although advantages of LHM improving surgical records in major anatomical liver resections were clarified, oncological advantages in the long-term survival of LHM was still uncertain in the hepatobiliary malignancies.     

Colorectal liver metastases: Hepatic pedicle clamping during hepatectomy reduces the incidence of tumor recurrence in selected patients. Case-matched analysis

Background

Hepatic pedicle clamping (HPC) during Liver Resection (LR) is a vascular procedure designed to prevent bleeding from the liver during hepatectomy. Outgrowth of pre-existing colorectal micrometastases may occur 5–6 times faster in occluded liver lobes than in non-occluded lobes. We conducted a case-matched analysis at our Institution to assess the effects of HPC on overall and recurrence-free survival in highly selected patients, who underwent LR due to Colorectal liver metastases (CLM).

Materials and methods

From January 2002 to December 2010, 120 patients operated for CLM were included into this case-matched study. Patients were allocated to two groups: Group-A patients who underwent HPC during LR; Group-B patients who underwent LR without HPC.

Results

HPC during liver resection was associated with better overall patient 5-year survival (47.2% in Group-A and 32.1% in Group-B) (P-value = 0.06), and significantly better 5-year recurrence-free survival (49.9% in Group-A vs 18.3% in Group-B) (P-value = 0.010) The Cox regression model identified the following risk factors for worse prognosis in terms of shorter recurrence-free survival and higher incidence of tumor recurrence: no HPC (Group-B) (P-value = 0.032) and positive lymph nodes at the time of LR (P-value = 0.018).

Conclusion

Lack of HPC in selected patients who underwent LR for CLM results to be a strong independent risk factor for higher patient exposure to tumor recurrence. We suggest that hepatic hilum clamping should be seriously taken into consideration in this patient setting.

Mini-abstract

A case-matched study was performed in 120 patients undergoing liver resection due to colorectal liver metastases, comparing patients who received intermittent hepatic pedicle clamping (HPC) with those who did not. The 5-year overall survival rate was similar, but the 5-year recurrence-free rate was significantly higher with no HPC (p = 0.012).     

Improving laser-induced thermotherapy of liver metastases--effects of arterial microembolization and complete blood flow occlusion.

INTRODUCTION: A prerequisite for an oncologically curative application of laser-induced thermotherapy (LITT) of liver metastases is complete tumor destruction. This increased effectiveness was achieved experimentally by combining LITT with interrupted hepatic perfusion. The aim of this study was to evaluate whether an interventional selective arterial microembolization might be as effective as complete blood flow occlusion using an open Pringle's maneuver. PATIENTS AND METHODS: We included patients with unresectable colorectal liver metastases. LITT was performed without interrupted hepatic perfusion (control group) compared to LITT in combination with interrupted perfusion either by embolization of intraarterial degradable starch microspheres (DSM) (percutaneous access) or by complete hepatic inflow occlusion (Pringle's maneuver; open access). Online monitoring was performed using intraoperative ultrasound or MRI. Volumetric techniques were used to assess metastases and postinterventional lesions. RESULTS: Fifty-six patients with 104 metastases (control group (25), DSM (37), and Pringle (42)) were treated. The preinterventional tumor volumes were significantly smaller than the postinterventional lesion volumes (control group: 9.8 vs. 25.3 cm3; DSM: 9.5 vs. 65.4 cm3; Pringle: 12.9 vs. 76.5 cm3). The morbidity rate was 21.4% without treatment-related mortalities. After 6 months follow-up, tumor recurrence was diagnosed in 6 patients (control group (4), LITT with DSM (1), and Pringle (1)). CONCLUSIONS: Combining LITT with blood flow occlusion leads to a significant increase in lesion size. The application of DSM offers a safe and effective alternative to the open access with Pringle's maneuver. Compared to LITT-monotherapy, this modality achieves significantly larger thermal lesions with the need of fewer applications.     

Isolated hypoxic hepatic perfusion with melphalan in patients with irresectable ocular melanoma metastases

Aim

Ocular melanoma prefers to metastasize to the liver and the liver is the sole site of metastatic disease in 80% of patients. Until now there has been no standard treatment available and these patients have a very poor prognosis (median survival 2–5 months). Isolated hepatic perfusion may be an option in patients with irresectable hepatic ocular melanoma metastases. The aim of this study was to evaluate applicability, toxicity and response in this selected group of ocular melanoma patients by treatment with isolated hypoxic hepatic perfusion with retrograde outflow (IHHP) with melphalan.

Methods

From September 2002 until July 2006 eight consecutive patients were included in this study. IHHP was performed with inflow via the hepatic artery and retrograde outflow via the portal vein during 25 min with 1 mg/kg melphalan. The perfusion was followed by a complete wash-out procedure.

Results

The median total operation time was 4 h with a median blood/fluid loss of 1100 ml. No postoperative mortality was observed. Median hospital stay was 9.5 days. Toxicity was moderate: WHO grade 3 leukocytopenia in 3 patients, grade 3 hepatic toxicity in 1 patient. In 37% of patients (3/8) a partial response could be demonstrated 3 months after IHHP. Stable disease was found in 3 patients and progressive disease in 2 patients. Median time to local progression was 6 months and the median survival was 11 months.

Conclusion

Melphalan-based IHHP with retrograde outflow is a safe treatment option for patients with irresectable ocular melanoma metastases. Survival benefit seems to be comparable to classical IHHP.     

A new measure to assess the difficulty of liver resection

Background

There is no valid measure to assess surgical difficulty and feasibility of a planned liver resection. It is the objective of this study to evaluate a mathematical measure from a 3D graphical analysis.

Methods

Eleven different 3D models of hepatic tumours were evaluated by experts for resectability and analysed with Amira^® graphic software taking into consideration the portal and hepatic venous vascular relationships. Virtual resection volumes with increasing resection margins from 1 to 30 mm were determined separately for portal veins, hepatic veins, their intersections and volume unions. The integral of the increasing resection volumes was defined as risk coefficient. The risk coefficients from this volumetric analysis were compared with the expert opinion.

Results

The risk coefficient based on the integral of portal venous and hepatic venous volume unions reproduced the expert opinion highly significantly (correlation coefficient 0.9, p < 0.05) and more accurately than volumetric analysis of the planned resection margin.

Conclusion

With automated volumetric analysis, anatomically problematic situations in liver surgery can be reproduced and scaled. The risk coefficient obtained is a suitable objective measure for defining risk areas in liver surgery.     

Preliminary experience with the hanging maneuver for pancreaticoduodenectomy

Background

Malignant periampullary tumours often invade retroperitoneal peripancreatic tissues and a positive resection margin following pancreaticoduodenectomy (PD) is associated with a poor survival. The margin most frequently invaded is the retroperitoneal margin (RM). Among the different steps of PD one of the most difficult and less codified is the resection of the RM with high risk of bleeding. We have developed a surgical technique – “hanging maneuver” – which allows at the same time a standardization of this step, a complete resection of the RM, and an optimal control of bleeding.

Patients/Methods

We described the surgical technique, and we reported our preliminary experience. Surgical data, postoperative outcome and pathological results of patients submitted to PD for pancreatic carcinoma using “hanging maneuver” technique between January 2007 and December 2007 were reviewed.

Results

The hanging maneuver was performed in 20 patients without any intraoperative complication and massive bleeding. No patient required blood transfusion. After had inked the surgical margins, retroperitoneal peripancreatic tissue was invaded in 12 out of 17 patients with malignant diseases (70.5%). In only one case (6%), the retroperitoneal margin was involved by the tumour (R1 resection).

Conclusion

The “hanging maneuver” is a useful and safe technical variant and should be considered in the armamentarium of the pancreatic surgeons in order to achieve negative retroperitoneal margins.     

Debulking surgery followed by intraarterial 5-fluorouracil chemotherapy plus subcutaneous interferon alfa for massive hepatocellular carcinoma with multiple intrahepatic metastases: A pilot study

Background

The prognosis in advanced hepatocellular carcinoma (HCC) with multiple intrahepatic metastases is extremely poor. Combination therapy with subcutaneous interferon (IFN) alfa and intraarterial 5-fluorouracil was reported to be effective against such advanced HCC. We describe results of debulking surgery followed by combination therapy with IFN alfa and 5-FU for massive HCC with multiple intrahepatic metastases.

Methods

In 27 HCC patients with massive tumors and multiple intrahepatic metastases, we performed combination therapy with IFN alfa and 5-FU after maximal liver tumor resection.

Results

Mean patient age was 63.3 years. Including intrahepatic metastases, tumors numbered 5 or more in 17 patients (63%). Portal or hepatic vein branches were invaded in 22 (81%). The mean maximum tumor diameter was 102 mm. Among 24 patients whose results were analyzed, an objective response by residual intrahepatic metastases was observed in 13 (54%; complete response in 12, and partial response in 1). Overall 1-, 3-, and 5-year survival was 73.2%, 38.7%, and 38.7%, respectively; 1-, 3-, and 5-year progression-free rates were 38.2%, 22.3%, and 22.3%.

Conclusions

Debulking surgery followed by IFN alfa and 5-FU combination chemotherapy offers possibility of long-term survival despite massive HCC with multiple intrahepatic metastases.     

Petrosal vein occlusion in cerebello-pontine angle tumour surgery: An anatomical study of alternative draining pathways

Objective

The present anatomic study investigates alternative draining pathways of the petrosal vein territory, which allow compensation in case of surgical sacrifice.

Methods

In eight (four formaldehyde fixed and four alcohol fixed) specimens the petrosal vein complex has been dissected and studied. Three heads have been selectively injected via the superior petrous sinus with colored silicon in two different colors. Thereafter the posterior fossa content was removed epidurally from the skull and further fixed in 4% formaldehyde. The nervous and vascular structures were dissected under microscopic control, measured and photographed. 3D-photographs were elaborated.

Results

The petrosal vein was present in all cases and joined the superior petrous sinus always lateral to the trigeminal nerve as a single trunk. In the selectively injected specimens no passage of the colored silicon mixture to the contralateral venous brainstem territory could be discerned. However, the ipsilateral anastomoses to the deep supratentorial venous system – peduncular, anterolateral pontomesencephalic, lateral mesencephalic veins, and the tectal veins in connection with the pontotrigeminal vein – filled in all cases.

Conclusion

Although the present anatomical model does not reflect physiological aspects of vascular dynamics, we document an apparently compensatory venous blood drainage occurring via anastomotic pathways directed to the ipsilateral supratentorial venous system. These findings represent an interesting aspect for preoperative image-guided planning in cerebello-pontine angle surgery.     

Laparoscopic anatomic liver resection of segment 7 using a caudo-dorsal approach to the right hepatic vein

BackgroundLaparoscopic anatomic liver resection of segment 7 (S7) is technically challenging because of the posterosuperior location and the lack of clear anatomical landmarks [[1], [2], [3], [4]]. Here, we introduce a caudo-dorsal approach, which may offer a benefit for the difficult procedure.MethodsThe patient was a 53-year-old man with hepatocellular carcinoma located in S7 of the liver. After the transection of caudate process, the Glissonean pedicle of S7 (G7) extending from the right posterior Glissonean pedicle was identified on the liver dorsal side. The demarcation line was noted by isolating and clamping G7. The intraoperative ultrasound was then used to assess the extent of the tumor. The right hepatic vein was approached from the dorsal side and continuously exposed in a caudal-cranial direction along the anterior surface of inferior vena cava after isolating and cutting the venous branches draining S7. Following the dissection of G7, the liver parenchymal transection was proceeded along the ischemic line between segment 6 and 7 with the ventral cutting plane extended to join the dorsal one. The liver parenchyma of the ventral side of the exposed right hepatic vein (RHV) was further transected from the dorsal side toward the root side of RHV. The resection of S7 was completed with perihepatic ligaments dissection.ResultsThe intermittent Pringle maneuver (15 min occlusion and 5 min reperfusion) was applied when necessary with a total time of 45 min. The operation time was 200 min, the estimated blood loss was 300 ml, and no transfusion was required. Pathology confirmed moderately differentiated HCC with negative surgical margin. The patient was discharged on postoperative day 8 with no complications and has been followed up for 8 months without recurrence.ConclusionThis caudo-dorsal approach for laparoscopic anatomical S7 segmentectomy is easy and feasible when performed by experienced surgeons at experienced centers in well-selected patients     

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.