Left trisegmentectomy and combined resection of the inferior vena cava, without reconstruction, for giant cystadenocarcinoma of the liver

A 54-year-old woman with giant liver cystadenocarcinoma underwent left trisegmentectomy with combined resection of the inferior vena cava (IVC) and the right hepatic vein. As a result, only the right inferior hepatic vein was preserved as a drainage vein. Because the perivertebral plexus and the azygos vein were both well developed, neither veno-venous bypass nor IVC reconstruction was performed. The developed collateral veins acted as the venous drainage pathway to maintain a stable systemic circulation. On the seventh postoperative day, portal vein flow dramatically decreased and the patient tended to liver failure. Prostaglandin E₁ (PGE₁) was administrated via the superior mesenteric artery. The portal flow then gradually increased and liver failure was avoided. Six months after the operation, she was re-admitted due to obstructive jaundice and presented with complete stenosis of the common bile duct (CBD). The jaundice persisted and liver dysfunction progressed. The patient died seven months after the operation. The confluence of the right inferior vein and the IVC could have been deformed, causing outflow blockade. The intrinsic shunt was not good enough to act as the drainage pathway, and IVC reconstruction may have been needed.     

Resection and reconstruction of the inferior vena cava for major hepatic resection]

The inferior vena cava (IVC) is partially or segmentally resected in major hepatic resection for malignant hepatic tumors in case of possible direct invasion to the IVC wall or IVC tumor thrombosis. The reconstruction methods of the IVC are divided into three categories depending on the degree of IVC resection: simple suture; patch repair; and segmental replacement. In segmental replacement, a synthetic material such as a cylindrical expanded polytetrafluoroethylene (ePTFE) grafts is widely utilized as a substitute. The total hepatic vascular exclusion technique is usually necessary in concomitant resection of the suprahepatic IVC. When a longer duration of hepatic vascular exclusion is required to resect and reconstruct the suprahepatic IVC and hepatic vein confluence, in situ hypothermic perfusion, the ante situm technique, or ex vivo bench surgery must be applied. When an ePTFE graft is replaced in the resected IVC, a Carrel patch of the IVC is used for the hepatic vein orifice to maintain anastomotic patency. Alternatively, the hepatic vein can be reanastomosed to an inferior vena caval segment transpositioned from the intact infrahepatic IVC portion by replacing the resected infrahepatic IVC with an ePTFE graft.     

Ex vivo extended left hepatectomy with caval preservation, temporary portacaval shunt, and reconstruction of the right hepatic vein outflow using a reversed portal vein bifurcation graft

Liver resections that require ex vivo techniques occur rarely, but when done are generally performed on veno-veno bypass to maintain venous return and decompress the portal circulation during the anhepatic phase of the procedure. We describe an ex vivo extended left hepatectomy that was performed with preservation of the inferior vena cava and the use of a temporary portacaval shunt to eliminate the need for veno-venous bypass. Ex vivo resection allowed reconstruction of right hepatic vein branches, using the patient's reversed portal vein bifurcation as a graft to provide venous outflow.     

New Left Lobe Transplantation Procedure with Caval Reconstruction Using an Inverted Composite Graft for Chronic Budd-Chiari Syndrome in Living-Donor Liver Transplantation—A Case Report

When the Budd-Chiari syndrome (BCS) lesion extends to the inferior vena cava (IVC) or the orifices of the hepatic vein, the thickened IVC and/or hepatic vein wall must be removed and IVC reconstruction is required in living-donor liver transplantation (LDLT). In various reports about IVC resection in LDLT for BCS, there are none about left lobe liver transplantation with reconstruction of the retrohepatic IVC (rhIVC). To overcome removal and reconstruction of the rhIVC in LDLT for BCS, we introduced a composite IVC graft that is applicable to both right and left lobe partial liver grafts for LDLT for BCS. Pathogenic IVC was removed together with the native liver between the lower edge of the right atrium and 5 cm above the renal vein junction with the use of venovenous bypass. The e-polytetrafluoroethylene graft was anastomosed to the suprarenal intact IVC. Then the native part was detached at the level of just above the renal junction. The composite graft was inverted and a half rim of the native part of the graft was anastomosed to the posterior wall of the right atrium. Next, the common venous orifice of the left lobe graft was anastomosed to the wall defect which was composed of the anterior wall of the right atrium and the distal end of the native part of the composite graft. In conclusion, our inverted composite graft technique will overcome the weak points of LDLT for BCS, such as incomplete removal of the pathogenic caval wall and reconstruction of the rhIVC.     

Left Renal Vein Graft for Vascular Reconstruction in Abdominal Malignancy

Background Advanced abdominal malignancies are occasionally invasive for the major blood vessels, such as the portal vein (PV), inferior vena cava (IVC), and major hepatic veins (HVs), and complete removal of the tumors is required for patients undergoing vascular resection and reconstruction. We used left renal vein (LRV) grafts for vascular reconstruction in patients with these malignancies and evaluated their clinical relevance. Methods A total of 113 patients underwent vascular resection including the PV (42 patients), IVC (68 patients), and HV (3 patients) for hepatobiliary-pancreatic or abdominal tumor resection. Of these, 11 patients underwent vascular reconstruction with a LRV graft of the PV, superior mesenteric vein (SMV), and HVs in 3 patients each, and the IVC in 2 patients. The HVs were resected with segmentectomy involving Couinaud’s segments VII, VIII, and IV; VII, VIII, and II; or III, IV, VIII in each patient. The PV and SMV were resected in 5 patients undergoing pancreaticoduodenectomy for pancreatic carcinoma, and in 1 patient being treated with extended right hepatectomy and pancreaticoduodenectomy for hepatic hilar carcinoma. The IVC was partially resected in 1 patient with advanced colon cancer and 1 with malignant schwannoma. Results The mean graft length of LRV obtained was 3.6 (3.5–4.0) cm. The graft was used as a tube in 9 patients, and as a patch in 2 patients. The mean duration of clamping time was 41.9 (35–60) min. Portal vein thrombosis was encountered in 2 patients, and anastomotic stenosis in 1 patient. Other morbidity was not related to vascular reconstruction. One patient who underwent extended right hepatectomy and pancreaticoduodenectomy died of liver failure in the hospital. The serum creatinine level after surgery did not deteriorate except in the one patient who died in the hospital. Graft patency was maintained during the follow-up period in all patients. Conclusions A LRV graft may enhance the possibility of vascular reconstruction without deteriorating serum creatinine level, and it provides sound graft patency.     

Indications for and techniques of hepatic vein reconstruction in hepatectomy for hepatocellular carcinoma]

The indications for hepatic vein reconstruction (HVR) in resection of segments 7 and 8 for hepatocellular carcinoma (HCC) have been controversial. Although right hepatic vein ligation may not cause complications in some patients, hepatic parenchymal congestion and liver dysfunction occur in others. We performed HVR using autovein grafts in 6 HCC patients, patch grafts in 3, and direct anastomosis in 1, respectively. From this experience, we consider that HVR may be indicated in patients with a discolored hepatic area after hepatic vein ligation, and without inferior right hepatic vein and intrahepatic venous communication. Furthermore, although repeat hepatectomy has resulted in improved survival in patients with recurrent hepatic tumors, when the right hepatic vein has already been ligated, numerous intrahepatic communicating vein anastomoses develop. In repeat hepatectomy in such patients, uncontrollable massive bleeding from hepatic veins occurs. Therefore, HVR is recommended to maintain the previous hepatic vein anatomy. Recently, the indications for HVR have been studied to prevent hepatic vein congestion and liver dysfunction in both the remant and graft livers in living-related donor partial liver transplantation from the standpoint of hemodynamics. Additionally, the technique of direct hepatic vein anastomosis is presented.     

Reconstruction of the hepatic vein using a patch graft from the autologous pericardium

We describe a patch graft technique using the autologous pericardium for reconstruction of the right hepatic vein after hepatectomy. A male patient underwent hepatectomy for removal of metastatic tumors from colon cancer. A 2.5-cm-diameter tumor, which was located in the antero-superior segment (S8) of the right lobe, invaded the right hepatic vein. A patch graft was obtained from the autologous pericardium. After clamping of the proximal and distal parts of the right hepatic vein invaded by the cancer, part of the anterior wall, measuring 2.0 x 1.5 cm, was resected. The patch fitted the defect in the right hepatic vein well and was sutured in place using running sutures of 6-0 Proline. Its patency was maintained 14 months after surgery. This technique can be applied for reconstruction after partial resection of a vein in this and other sites.     

Hepatobiliary resection with concomitant resection of the inferior vena cava for advanced intrahepatic cholangiocarcinoma: report of a case

A 65-year-old female was diagnosed with intrahepatic cholangiocarcinoma involving the inferior vena cava (IVC). The patient underwent right trisectionectomy and caudate lobectomy with bile duct resection and concomitant resection of the IVC. The IVC was reconstructed using the right external iliac vein. Histologically, the tumor had invaded the IVC. Despite the administration of postoperative prophylactic anticoagulant therapy, IVC thrombosis developed, probably due to the difference in diameter between the IVC and the graft. Following the development of collateral vessels, the patient was discharged and is now healthy without recurrence 18 months after surgery. IVC reconstruction using an external iliac vein graft may lead to the development of IVC thrombosis. Therefore, the graft used for IVC reconstruction should be very carefully selected.     

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.     

Is combined partial hepatectomy with segmental resection of inferior vena cava justified for malignancy?

HYPOTHESIS: En bloc partial hepatectomy with inferior vena cava (IVC) resection may be the only curative strategy for patients with hepatic malignancies involving the IVC. DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS: All consecutive patients undergoing combined partial hepatectomy with segmental IVC resection and reconstruction between 1990 and 2002. Patients with tangential excision of the IVC were excluded. Follow-up was completed by outpatient clinic visits and mail correspondence. MAIN OUTCOME MEASURES: Perioperative outcomes; overall and recurrence-free survival. RESULTS: Nineteen patients (7 men and 12 women) underwent partial hepatectomy and segmental IVC resection and reconstruction. Median age was 59 years (range, 24-74 years). Diagnoses consisted of cholangiocarcinoma (9 patients), metastatic tumor (5 patients), sarcoma (3 patients), and hepatocellular carcinoma (2 patients). Major hepatectomies (>/=3 segments) were performed in 15 patients; the caudate lobe was resected in 13. Hepatic vascular isolation was used in 13 patients. Ringed polytef grafts were used for IVC reconstruction in all but 1 patient. Transfusion was necessary in 18 patients (median requirement, 5 U). Median operative time was 6.3 hours (range, 3.7-9.0 hours), and hospitalization was 10.5 days (range, 6-41 days). Negative margins of resection were achieved in 16 patients. Complications occurred in 8 patients (42%), including 1 perioperative death (5%). There was evidence of mural thrombosis of the graft in 2 patients (both nonocclusive); warfarin sodium was used postoperatively in 14. Late graft thrombosis was evident in 2 patients. Median overall survival was 38 months (5-year survival, 21%), and recurrence-free survival was 11.5 months (5-year survival, 0%). CONCLUSIONS: Patients with large tumors involving both the liver and the IVC are candidates for partial hepatectomy and segmental IVC resection. Resection affords the possibility of negative margins, acceptable perioperative morbidity and mortality, long-term graft patency, and prolonged survival.     

Surgical treatment for colorectal liver metastases involving the paracaval portion of the caudate lobe

BACKGROUND: Hepatic neoplasms in the paracaval portion of the caudate lobe (S1r) are usually difficult to treat surgically because such neoplasms often invade the hepatic veins and/or inferior vena cava (IVC). We reevaluated resected cases of colorectal liver metastases involving S1r to confirm the significance of aggressive surgical treatments. METHODS: Between July 1977 and December 2002, 95 consecutive patients with colorectal liver metastases underwent hepatic resection. Seven patients with liver metastases involving the S1r underwent resection. RESULTS: The surgical procedures for liver metastases comprised 3 isolated caudate lobectomies, 2 right hepatectomies, and 2 right hepatic trisectionectomies with caudate lobectomy. Combined resections included partial resection of the hepatic vein in 2 patients, wedge resection of the IVC in 3, and segmental resection of the IVC in 1. Six of the 7 patients with S1r metastasis had recurrent disease in liver and/or lung. A second hepatectomy was carried out in 4 patients and a partial lung resection in 2 patients. Four of the 7 patients survived more than 5 years, but 2 of them died of recurrent disease at 61 and 95 months after initial hepatectomy. The remaining 2 patients are alive 72 and 118 months without any sign of recurrence. The median survival time of the 7 patients was 60 months. CONCLUSION: Liver metastases involving the S1r could be resected radically with en bloc resection of the major hepatic veins and/or the inferior vena cava. An aggressive surgical approach with combined resection of the adjacent major vessels may offer a better chance of long-term survival in selected patients with caudate lobe metastasis from colorectal cancer.     

Hepatobiliary resection with inferior vena cava resection and reconstruction using an autologous patch graft for intrahepatic cholangiocarcinoma

Background In patients with advanced cholangiocarcinoma involving the inferior vena cava (IVC), an extended hepatobiliary resection with combined resection and reconstruction of the IVC is often prerequisite to obtain a clear resection margin. Materials and methods We present our approach to repair of approximately half of a cross-sectional wall defect of the IVC using an autologous external iliac venous patch graft during extended hepatobiliary resection with a total hepatic vascular exclusion technique. The harvested external iliac vein graft was incised longitudinally and trimmed to fit the IVC defect. After multiple stay sutures, a continuous running suture using 4–0 prolene was made. Results Two patients who underwent this complex surgery survive 20 and 27 months after surgery, respectively. Morbidity of transient edema of the ipsilateral lower leg potentially related to graft harvesting was noted in one patient after surgery. Conclusions The external iliac vein patch graft for IVC resection and reconstruction during hepatobiliary resection is technically simple, produces no stenosis or caliber change in the reconstructed IVC, and is applicable for at least half or less of a cross-sectional defect of the IVC wall to be reconstructed.     

Venous reconstruction of the inferior vena cava bifurcation for retroperitoneal rhabdomyosarcoma in a child. Case report

Retroperitoneal tumors, as well as traumatic lesions and occlusions of the bifurcation of the inferior vena cava (IVC) and the common iliac veins may require venous vascular reconstruction. We present a method for inferior vena caval bifurcation reconstruction which employs the advantages of a large size straight expanded polytetrafluorethylene (ePTFE) graft in this position after a new IVC bifurcation has been created by uniting the stumps of both common iliac veins, and construction of an arteriovenous (A-V) fistula with controlled flow to decrease the rethrombosis rate of the graft, and still not cause heart failure. This method was used in a case of recurrent rhabdomyosarcoma in an 8 year old child encroaching upon the bifurcation of the IVC as well as on both common iliac veins. The situation was managed by radical resection of the tumor and by creating a new caval bifurcation of the common iliac veins, followed by interposition of a straight ePTFE graft. An A-V fistula was created between the left femoral vein and left femoral artery using the left greater saphenous vein in controlled fashion. The arterial defect of the right common iliac artery was reconstructed by interposition of a PTFE graft end-to-end.     

Caudate lobectomy combined with resection of the inferior vena cava and its reconstruction by a pericardial autograft patch

A 53-year-old woman with remnant liver metastasis originating from colon cancer was referred to our department. She underwent successful caudate lobectomy combined with resection of the inferior vena cava (IVC), including reconstruction with a pericardial autograft patch. IVC clamping was performed between the IVC below the confluence of the left hepatic vein and the infrahepatic IVC in order to preserve the hepatic circulation. After 18 months, the graft was patent and there was no sign of recurrence. A part of the pericardium used as an autograft for patch repair of the defect of the IVC was very useful because it was easily available, required only division of the diaphragm, and was of sufficient length and width.     

Extension incision for renal carcinoma including invaded vena cava and right lobe of liver.

We report on a thirty-five-year-old woman with renal cell carcinoma who successfully underwent right radical nephrectomy and extended right hepatic lobectomy with resection and reconstruction of inferior vena cava (IVC). A temporary bypass was placed between the infrarenal IVC and right atrium using a heparin-coated synthetic tube. The tumor was resected en bloc including right kidney, adrenal gland, hepatic lobe, and IVC. The IVC was reconstructed using an expanded polytetrafluoroethylene (EPTFE) graft. Her postoperative course was uneventful with no signs of recurrence four years after surgery.     

Preoperative hepatic venous embolization for partial hepatectomy combined with segmental resection of major hepatic vein

BACKGROUND: Liver resection of segments VII and/or VIII sometimes requires segmental resection of the right hepatic vein in patients with liver tumours invading or located close to the hepatic vein. In this situation, hepatic vein reconstruction is thought to have an important role in the postoperative function of segment VI. This study investigated whether preoperative embolization of the major hepatic vein could obviate the need for hepatic vein reconstruction after cranial partial resection of the liver including the major hepatic vein trunk in a preclinical model. METHODS: Sixteen beagles were divided into two groups of eight: control group (hepatectomy alone) and hepatic venous embolization (HVE) group (hepatectomy after HVE). HVE was performed 2 weeks before hepatectomy. All dogs underwent resection of the cranial third of the left lateral liver lobe together with the major trunk of the left hepatic vein. Following hepatectomy, survival, histological features, portal venous pressure and serum aspartate aminotransferase (AST) levels were determined. RESULTS: Six control animals and seven in the HVE group were alive 1 week after hepatectomy. Immediately after hepatectomy, portal venous pressure was significantly higher in the control group compared with the HVE group (mean(s.d.) 14.0(1.1) versus 8.1(1.0) mmHg; P < 0.01). Histological examination of the remnant left lateral lobe demonstrated patchy parenchymal haemorrhage in the control group and normal parenchymal architecture in the HVE group. Peak AST levels were observed on day 1 in both groups and were significantly higher in the control group (mean(s.d.) 182(42) versus 67(40) units/l; P < 0.01). CONCLUSION: In this model, preoperative HVE facilitated interlobar venous collateral formation and minimized the untoward effects of segmental hepatic vein resection. This procedure may obviate the need for hepatic vein reconstruction after cranial partial liver resection including the major hepatic vein.     

下腔静脉重建联合肝叶切除治疗肝癌的初步研究

目的 探讨在全肝血流控制下不采用静脉转流技术行下腔静脉重建的肝叶切除治疗侵犯下腔静脉的肝癌的临床经验和疗效。方法 自2004年8月至2005年7月，对3例胆管细胞性肝癌和2例肝细胞性肝癌合并下腔静脉直接侵犯而无癌栓患者，在全肝血流控制而无静脉转流技术下行解剖性肝叶切除联合下腔静脉重建术（局部切除修复2例、局部切除补片2例、人工血管移植1例）。结果 5例患者手术均成功。平均手术时间345（300～450）min，平均手术失血量1375（1200～1800）ml。累计平均肝门阻断时间、全肝血流阻断时间和下腔静脉阻断时间分别为19min、21．2min、56min。术后发生胸腔积液1例，胆漏1例，腹水1例，均治愈。患者平均住院时间15．5（11～19）d。随访4～15个月，1例术后9个月死于肿瘤复发，4例已存活4、8、10、15个月。结论 在全肝血流控制而无静脉转流技术下行下腔静脉重建联合解剖性肝叶切除治疗直接侵犯下腔静脉的肝癌不仅可安全施行，而且可延长患者生存时间。     

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. Received: March 27, 2000 / Accepted: August 8, 2000     

下腔静脉及肝静脉短段病变型布-加氏综合征的外科治疗

目的 探讨布-加氏综合征的下腔静脉短段闭塞及肝静脉主干病变根治性切除的优缺点、术中的注意事项。方法 下腔静脉闭塞或狭窄段切除、人工血管原位移植术42例,肝静脉主干闭塞段切除、肝静脉流出道成形、人工血管原位移植术10例,肝静脉主干闭塞段切除、肝静脉-右心房吻合3例,经皮肝穿肝或副肝静脉破膜、扩张10例。结果 1例死于并发症,随访58例,平均30个月,介入复发3例,手术复发1例。结论 下腔静脉或肝静脉病变段切除、人工血管原位移植治疗布-加氏综合征,能根治病变、符合正常解剖生理、远期疗效好。     

活体肝移植的几点关键外科技术

目的：探讨活体肝移植的几点关键外科技术。方法：2001年1月至2002年3月底,实施活体肝移植11例,其中左半肝8例,左外叶1例,成人右半肝2例;根据术前CT、血管造影和术中B超确定肝切除线,超声电刀离断肝实质,经门静脉灌注原位获取。受体手术采用保留腔静脉的全肝切除。移植肝原位植入,肝静脉重建采用扩大成型吻合技术,显微技术吻合肝动脉,胆道重建采用端端吻合,置“T“管引流。结果：11例供体术后顺利康复出院,未发生严重并发症。11例受体中,1例发生肝动脉血栓形成需再次肝移植,1例因不可逆转的严重排斥反应,于术后72d死亡。10例受体康复出院,肝功能、铜氧化酶恢复正常。结论：活体肝移植对供体是相对安全的。管道重建技术是活体肝移植的重要环节。术前、术中了解供体的解剖变异并正确处理,可降低并发症发生率。