Intracaval endovascular ultrasonography for large adrenal and retroperitoneal tumors

BACKGROUND: An accurate diagnosis of inferior vena cava (IVC) invasion is important in deciding the surgical strategy for a large adrenal tumor. We investigated the diagnostic value of intracaval endovascular ultrasonography (ICEUS) for invasion of the IVC by a large adrenal tumor. METHODS: Nine of 163 patients with adrenal and retroperitoneal tumors underwent ICEUS between 1993 and 2002. Intravascular ultrasonography was performed through the right femoral vein with the use of an 8Fr, 20-MHz transducer. The diagnostic criterion for detecting IVC invasion with ICEUS was identification of destruction of a single echogenic layer of the IVC wall or identification of an intracaval tumor mass. The ICEUS finding was confirmed by pathologic examination. RESULTS: The mean diameter of the tumors in 9 patients undergoing ICEUS and resection was 12.6 cm (range, 8.6-16 cm). Pathologic diagnosis varied: adrenocortical carcinoma, 4; malignant pheochromocytoma, 1; leiomyosarcoma, 1; metastatic lung cancer, 1; paraganglioma, 1; and neurilemmoma, 1. Vascular invasion was identified in 2 patients by ICEUS and confirmed by examination of resected specimens. The sensitivity, specificity, and positive predictive values of ICEUS for the diagnosis of the IVC invasion were 100%, 100%, and 100%, respectively. However, these values for computed tomography were 100%, 14%, and 25%, respectively; and for cavography, 100%, 57%, and 40%, respectively. CONCLUSIONS: ICEUS provides confirmatory information regarding tumor invasion of the IVC. This modality also can assist in formulating an operative strategy for large adrenal or retroperitoneal tumors.     

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.     

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.     

Extent of pathologic invasion of the inferior vena cava in resected liver cancer compared with possible caval invasion diagnosed by preoperative images

The extent of cancerous invasion of the inferior vena cava (IVC) determined from resected liver cancer was examined pathologically. Ten patients presenting with liver cancer (metastatic liver cancer, five patients; hepatocellular carcinoma, three; and cholangiocellular carcinoma, two) were diagnosed with positive IVC invasion using preoperative imaging techniques of extracorporeal ultrasonography, computed tomography, magnetic resonance imaging, and vena cavography. The diagnostic criterion for positive IVC invasion by preoperative imaging was longitudinal IVC compression measuring over 50 mm, or transverse IVC compression extending to more than half the circumference of the IVC, or the presence of lesions protruding into the IVC lumen, or the presence of developed collateral veins. All patients underwent combined resection of the IVC. However, pathology results revealed that four of the ten patients had no cancerous invasion of the IVC, and that the extent of invasion along both the longitudinal and transverse axes of the IVC was much smaller than the compression shown by imaging results. We believe that detailed preoperative assessment, using a more precise imaging technique, as well as further intraoperative examination, is required to predict the full pathological extent of cancerous invasion of the IVC. Received for publication on Jan. 14, 2000; accepted on April 5, 2000     

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.     

Combined Liver and Inferior Vena Cava Resection for Adrenocortical Carcinoma

Purpose Adrenocortical carcinoma (ACC) is a rare malignancy, usually diagnosed at an advanced stage when it has invaded or adhered to adjacent organs. We report our experience of performing combined liver and inferior vena cava (IVC) resection for ACC. Methods Six patients with clinical stage III (n = 4) or IV (n = 2) ACC underwent combined resection of the liver and IVC. Two patients underwent extended right hepatectomy, and four underwent segmentectomy. In four patients, the IVC was resected segmentally: it was replaced with expanded polytetrafluoroethylene (ePTFE) in three of these patients, and not reconstructed in one. In two patients, the IVC was partially resected and closed directly. Results Perioperative mortality was zero, and morbidity was 33.3%, with temporary liver failure in two patients and renal failure in one patient. Recurrence was found within 8.1 months in three (50%) of the six patients. The mean recurrence-free survival period was 20.1 ± 7.7 months (95% confidence interval [CI]: 5.1–35.4), and the median survival time was 6.1 ± 9.8 months (95% CI: 00–25.3). The 5-year disease-free survival rate was 16.7%. Conclusions Patients with ACC involving both the liver and IVC are candidates for partial hepatectomy and segmental IVC resection. Resection affords the possibility of negative margins, acceptable perioperative morbidity and mortality, and prolonged survival in some patients.     

Ex vivo and in situ resection of inferior vena cava with hepatectomy for colorectal metastases

OBJECTIVE: To describe the surgical techniques and early results of inferior vena cava (IVC) resection in patients with advanced liver tumors. SUMMARY BACKGROUND DATA: Involvement of the IVC by hepatic tumors, although rare, is considered inoperable by standard resection techniques. Concomitant hepatic and IVC resection is required to achieve adequate tumor clearance. METHODS: Between February 1995 and February 1999, 158 patients underwent hepatic resection for colorectal metastases in the authors' unit. Eight patients, aged 42 to 80 years (mean 62 years), with hepatic metastases from colorectal cancer underwent concomitant resection of the IVC and four to six hepatic segments. Resections were carried out under total hepatic vascular exclusion in four patients and ex vivo in four patients. Between 30 degrees and 360 degrees of the retrohepatic IVC was resected and replaced with an autogenous vein patch (n = 1), a ringed Gore-Tex tube graft (n = 2), a Dacron tube graft (n = 1), or a patch (n = 3) or was repaired by primary suturing (n = 1). RESULTS: There were two early deaths from multiple organ failure. One patient survived 30 months after ex vivo resection but died of renal cell carcinoma, and another died with recurrent disease at 9 months. The remaining four patients remained alive 5 to 12 months after surgery, with no hepatic failure or venous obstruction; tumor recurrence was present in two. Nonthrombotic occlusion of the neocava occurred in one patient and was stented successfully. CONCLUSIONS: Although concomitant hepatic and IVC resection is associated with a considerable surgical risk, this aggressive surgical approach offers hope for patients with hepatic tumors involving the IVC, who would otherwise have a dismal prognosis. This procedure can be performed under total hepatic vascular exclusion, with or without venovenous bypass, and by ex vivo bench resection.     

Significance of hepatic resection combined with inferior vena cava resection and its reconstruction with expanded polytetrafluoroethylene for treatment of liver tumors

BACKGROUND: Resection of the IVC is required when a liver tumor invading the IVC is completely removed. The purpose of this study was to evaluate the clinical significance of hepatectomy combined with IVC resection and reconstruction with an ePTFE graft for treatment of invasive liver tumors and to discuss the validity of this surgery. STUDY DESIGN: Eleven selected patients with liver tumors underwent various types of hepatectomy with retrohepatic IVC resection, followed by IVC reconstruction. The postoperative courses, clinicopathologic features of the tumors, operative procedures, and outcomes of the patients were studied. RESULTS: Ten of 11 patients did not require an active ventriculovenous bypass using a biopump. Invasion to the IVC was histologically proved in 9 of the 11 patients. After reconstruction, all artificial vessel grafts maintained patency throughout the observation period. Four patients are still alive with cancer-free status ranging from approximately 11 years to 5 months. One-year, 3-year, and 5-year survival rates were 63.6%, 38.2%, and 25.5%, respectively, with a 50% survival of 29 months. CONCLUSIONS: IVC resection and its reconstruction with ePTFE for treatment of liver tumors was safely performed on 11 selected patients with a 50% survival of 29 months. Patency of the graft was maintained for the longterm without infectious complications. This surgical procedure is indicated in some select patients in whom IVC invasion is extensive.     

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     

Surgical results of left lobectomy and left hepatectomy in 70 noncirrhotic patients

As a preliminary step before performing liver transplantation using living related donors, a comparative study was undertaken to determine the specific operative risk of left lobectomy (n=54) compared to left hepatectomy (n=16) in noncirrhotic patients. No postoperative death was observed in either group and no patients required reoperation. The mean hospital stay was longer after left hepatectomy than after left lobectomy (23±15 days vs 10±3 days, P<0.05). The postoperative course was uneventful in 94% of the patients after left lobectomy and in 44% after left hepatectomy (P<0.001). The peroperative transfusion rate was higher after left hepatectomy than after left lobectomy (38% vs 4%, P=0.001). The postoperative collection rate was higher after left hepatectomy than after left lobectomy (25% vs 6%, NS). No biliary fistulas or subphrenic abscesses were noted after left lobectomy; however, these were observed in 19% and 12% of the cases, respectively, after left hepatectomy. Although conventional liver resection is quite different from graft harvesting in living related transplantation, our study demonstrates that the morbidity rate is significantly higher after left hepatectomy than after left lobectomy.     

Role for extending hepatic resection using an aggressive approach to liver surgery

BACKGROUND: The definition of what is unresectable in liver surgery is controversial. Problems that many believe render patients unresectable can currently be resected using advanced techniques of liver surgery. This study assesses liver resection in patients who were unresectable with standard liver resection but were potentially resectable using an aggressive approach to liver surgery. STUDY DESIGN: From 1997 to 2007, 830 adult patients undergoing hepatectomy were reviewed. Patients were categorized as having unresectable disease by standard resection if the disease could not be resected without resection of the IVC, hepatic vasculature, or because of tumor extent. RESULTS: One hundred sixteen patients were initially believed to have unresectable disease but went on to laparotomy. Eighteen patients were unresectable at operation, although 98 patients were resected. Seventy-eight trisectionectomies; 18 lobectomies; 1 mesohepatectomy; and 1 segment 5, 6 resection, combined with pancreaticoduodenectomy, nephrectomy, and colectomy, were performed. Fourteen patients also had pancreatic resections. Vascular reconstructions were performed on the IVC (n = 35), hepatic veins (n = 21), portal vein (n = 34), and hepatic artery (n = 5). Hypothermic perfusion of the liver was used in 12 patients (4 ex vivo, 8 in situ cold perfusion). Patients undergoing resection had 6% mortality with a morbidity of 35%. Median survival was 37 months (95% CI, 34-42 months). Five-year actuarial survival was 32%. CONCLUSIONS: Patients with liver tumors considered "unresectable" by standard liver resection should be considered for resection with an aggressive approach to liver surgery. Five-year survival of approximately one-third of patients can be expected.     

Caval invasion by liver tumor is limited

BACKGROUND: Successful hepatic resection with combined inferior vena cava (IVC) resection has been reported. The necessity of a combined IVC resection for hepatic malignancies that have attached to the IVC has not been fully evaluated. STUDY DESIGN: In this retrospective study, 162 lesions for which preoperative CT findings suggested attachment to the IVC were evaluated. Patient survival rates were examined according to type of tumor and the operative procedure. For adenocarcinoma lesions, several CT findings, including extent of the IVC circumference attached to the tumor compared with the whole IVC circumference (E(IVC)), were evaluated in conjunction with IVC resection. RESULTS: Among 162 lesions, 18 adenocarcinoma lesions were resected in combination with an IVC resection. Histologic IVC invasion was confirmed in eight patients. None of the 67 hepatocellular carcinoma lesions required concomitant IVC resection. Overall 5-year survival rate of the patients who underwent concomitant liver and IVC resections was 33.1%. Among the adenocarcinoma lesions, the positive predictive factors for IVC resection were an E(IVC) value > 25% and a peaked deformity of the IVC wall, according to a multivariate analysis. CONCLUSIONS: Most hepatic malignancies attached to the IVC wall can be completely removed without IVC resection. E(IVC) and deformity of the IVC on CT can be useful indicators for a concomitant liver and IVC resection. Careful separation of the liver and IVC is a key point for minimizing the size of the resected IVC and to avoid unnecessary IVC resection.     

Rekonstruktion der Vena cava inferior zur erweiterten Resektion maligner Tumoren

OBJECTIVES: Malignant tumor invasion in the inferior vena cava (IVC) has for a long time been the limiting factor in the resection of retroperitoneal tumors. The clinical outcome in these patients depends on vascular surgical techniques, the central role of which is played by IVC reconstruction. METHODS: Within the last 7 years, 9,085 vascular reconstructive procedures were performed in our department. Six patients suffered from retroperitoneal invasion of tumor into the IVC. After tumor resection, the involved IVC segments were replaced by polytetrafluorethylene (PTFE) grafts to restore IVC continuity. In three patients, an adjunctive arteriovenous (AV) fistula was constructed. RESULTS: The graft patency after a mean follow-up of 30.2 months (range 1 to 79) was 83.3%. The only graft occlusion occurred in a patient without AV fistula. There were no perioperative deaths and no major complications demanding reoperation. CONCLUSION: In patients with tumor involvement of the IVC, clinical outcome depends on vascular surgical coprocedure. After resection of the IVC, a PTFE graft should be interposed in combination with an AV fistula. Anticoagulation and CT scan are recommended after 3 months before ligation of the AV fistula.     

Hepatectomy with portal vein resection for hilar cholangiocarcinoma: audit of 52 consecutive cases

OBJECTIVE: To better determine the role of portal vein resection and its effect on survival, as well as to appreciate the impact of portal vein invasion on prognosis in hilar cholangiocarcinoma. SUMMARY BACKGROUND DATA: Hepatectomy with portal vein resection is sometimes performed for locally advanced hilar cholangiocarcinoma. However, the significance of microscopic invasion of the portal vein has not been determined. METHODS: Medical records of 160 patients with hilar cholangiocarcinoma who underwent macroscopically curative hepatectomy with (n = 52) or without portal vein resection (n = 108) were reviewed. Invasion of the portal vein was assessed histologically on the surgical specimen, and results were correlated with clinicopathologic features and survival. RESULTS: Surgical mortality, including all hospital deaths, was similar in patients who did and did not undergo portal vein resection (9.6% vs. 9.3%), but the primary tumor was more advanced in patients who underwent portal vein resection. Histologically, no invasion was found in 16 (30.8%) of resected portal veins. However, dense fibrosis adjacent to the portal vein was common, and the mean distance between the leading edge of cancer cells and the adventitia of the portal vein was 437 +/- 431 mum. The prognosis was worse in patients with than without portal vein resection (5-year survival, 9.9% vs. 36.8%; P < 0.0001). The presence or absence of microscopic invasion of the resected portal vein did not influence survival (16.6 months in patients with microscopic invasion vs. 19.4 months in those without; P = 0.1506). Multivariate analysis identified histologic differentiation, lymph node metastasis, and macroscopic portal vein invasion as independent prognostic factors. CONCLUSIONS: Microscopic invasion of the portal vein may be misdiagnosed clinically in patients with hilar cholangiocarcinoma. However, the distance between tumor and adventitia is so narrow that curative resection without portal vein resection is unlikely to be possible. Gross portal vein invasion has a negative impact on survival, and hepatectomy with portal vein resection can offer long-term survival in some patients with advanced hilar cholangiocarcinoma.     

Analysis of factors affecting long-term survival of patients with hepatocellular carcinoma following hepatectomy

The survival of 200 patients (172 males, 28 females; mean age ± SD: 53.6 ± 12 years) who underwent hepatectomy for hepatocellular carcinoma (HCC) was analyzed retrospectively to identify prognostic determinants to guide patient selection for appropriate treatment. All patients studied had had complete macroscopic extirpation of their tumor, histologic information regarding their lesions and the adjacent non-tumorous liver parenchyma, and no evidence of residual or recurrent disease 30 days after surgery. Survival was analyzed with reference to 25 different clinical (n=7), serological (n=2), macroscopic (n=4), and histological (n=12) features of the resected specimens, by using multivariate analysis. Recurrent HCC was detected in 138 patients within a median follow-up period of 12.6 months. While 33 patients had extra-hepatic disease alone, in 74, the recurrence was confined to the hepatic remnant. Survival at 1, 3, and 5 years was 58%, 34%, and 26%, respectively. The presence of residual histologic disease at the resection margin was found to be the only important prognostic determinant (P < 0.02). The distance of the macroscopic resection margin, either at 1 or 2 cm, made no difference to the long-term outcome of our patients. Following hepatectomy, a detailed pathologic examination of the resected liver specimen is mandatory to verify the status of disease clearance, as the distance of the gross surgical margin is an unreliable index.     

Surgical Resection of Primary Tumors in Patients Who Present With Stage IV Colorectal Cancer: An Analysis of Surveillance,Epidemiology, and End Results Data, 1988 to 2000

Background Surgical resection of the primary tumor for patients who present with incurable stage IV colorectal cancer is controversial. National practice patterns have not been described. We evaluated the use of primary tumor resection in patients presenting with stage IV colorectal cancer.Methods Patients with stage IV colorectal cancer diagnosed between 1988 and 2000 were selected from the Surveillance, Epidemiology, and End Results database. Patients undergoing primary tumor resection were analyzed on the basis of sex, race, year of diagnosis, and the anatomical site of the primary tumor. We compared the survival of resected and nonresected patients.Results A total of 17,658 (66%) of the 26,754 patients presenting with stage IV colorectal cancer underwent primary tumor resection. Patients with resected disease were more likely to be young (mean age of 67.1 vs. 70.3 years) and to have right-sided tumors (75.3%, 73.0%, and 45.6%, respectively, for right, left, and rectal; P < .001). In all age groups, patients undergoing resection had higher median and 1-year survival rates (colon: 11 vs. 2 months, 45% vs. 12%, P < .001; rectum: 16 vs. 6 months, 59% vs. 25%, P < .001) when compared with patients who did not undergo resection.Conclusions Most patients who present with stage IV colorectal cancer undergo resection of the primary tumor. The proportion of patients undergoing resection depends on patient age and race and the anatomical location of the primary tumor. The degree to which case selection explains the treatment and survival differences observed is not known. Further investigation of the role of surgery in the management of incurable stage IV colorectal cancer is warranted.Presented at the 57th Annual Cancer Symposium of the Society of Surgical Oncology, New York, New York, March 18–21, 2004.Published by Springer Science+Business Media, Inc. © 2005 The Society of Surgical Oncology, Inc.     

Giant cavernous hemangioma of the liver: is tumor size a risk factor for hepatectomy?

The aim of this study was to evaluate whether hepatic giant cavernous hemangioma (GCH) tumor size is a risk factor for hepatectomy. Twenty patients with GCH of the liver were treated by hepatic resection. Eleven patients with maximum resected specimen tumor size of >10 cm (mean tumor size, 18.5 cm; group 1) were compared with the 9 patients with tumor size. <10 cm (mean tumor size, 8.6 cm; group 2). The incidence of major hepatectomy in group 1 was significantly higher than that in group 2 (P = 0.0241). Although there were no significant differences in preoperative liver function, or in fibrinogen or platelet counts between the two groups, the level of preoperative fibrin degradation product (FDP) in group 1 was significantly higher than that in group 2 (P = 0.0116). Mean intraoperative hemorrhage volume, blood transfusion volume, and operation time in group 1 vs group 2 were 7003 ml vs 1092 ml (P = 0.0251), 2927 ml vs 556 ml (P = 0.0169), and 431 min vs 216 min (P < 0.0001), respectively. The incidence of postoperative complications in group 1 (45.5%) was higher than that in group 2 (22.2%), although not significantly so. There was no operative mortality in either group. Tumor size significantly correlated with intraoperative blood loss, operation time, weight of resected liver, intraoperative blood transfusion volume, and preoperative FDP levels. GCH tumor size is a significant risk factor for hepatectomy mainly because of the massive intraoperative blood loss and blood transfusion associated with major hepatic resection. More careful preoperative management to decrease tumor size may increase the safety of surgery for GCH of the liver. Received for publication on Jan. 21, 1999; accepted on May 24, 1999     

Surgical treatment for hilar cholangiocarcinoma

From September 1976 to February 1998, we experienced 75 resected patients with hilar cholangiocarcinoma. Curative resection was performed in 45 patients (60.0%), with a cumulative 5-year survival rate of 39.8%. In this retrospective study, we compared therapeutic outcomes in these 75 patients according to the period during which they were treated; (1) 12 patients in the early period (September 1976 to August 1981) chiefly treated by bile duct resection, (2) 50 patients in the middle period, September 1981 to August 1994, chiefly treated by aggressive surgical procedures with extensive hepatectomy plus caudate lobe resection, and (3) 13 patients in the late period, September 1994 to February 1998, during which percutaneous transhepatic portal embolization was introduced to increase the safety and curability of extended hepatectomy, and limited hepatectomy was selected according to tumor spread. In the late period, total resection of the caudate lobe was done in all patients, with the aim being thorough resection of cancer cells in the caudate lobe. The curative resection rates were 16.7% in the early period, 64.0% in the middle period, and 84.6% in the late period, showing an improvement year-by-year (P < 0.05; early period vs middle period and late period). All patients in the early period died within 2 years of resection, whereas the 5-year survival rate in the middle period was 24.4%, significantly improved (P < 0.05) compared with the early period. The 1- and 3-year survival rates of 84.6% and 58.0%, respectively, in the late period, show an even greater improvement in outcome. Received for publication on Oct. 5, 1998; accepted on Oct. 5, 1998     

In situ graft-trimming method using polyester vascular prosthesis for inferior vena cava reconstruction after hepatectomy

Hepatectomy for secondary liver cancer that has invaded the inferior vena cava (IVC) can be the only way to achieve long-term survival. We describe a method for hepatectomy combined with partial IVC resection without venous bypass circulation and an in situ graft-trimming method to avoid graft size mismatch after reconstruction. We carried out left hepatectomy extended to segment 1 with partial IVC resection first. During resection and reconstruction of the IVC, it was clamped below the right hepatic vein and above the inferior right hepatic vein to maintain systemic circulation. The graft was trimmed in situ, after a half running suture of the graft was finished to ensure the correct size. Preservation of both inferior right hepatic vein and right hepatic vein helps to maintain systemic circulation during reconstruction of the IVC. The in situ graft-trimming method is an easy and safe method to ensure the correct graft size after IVC reconstruction.     

Liver Resection for Primarily Unresectable Colorectal Metastases Downsized by Chemotherapy

This study was performed prospectively to assess the effect of systemic chemotherapy (FOLFIRI protocol) in patients with initially unresectable colorectal liver metastases (CRLM) and, after performing liver resection in patients with downsized metastases, to compare the postoperative and long-term results with those of patients with primarily resectable CRLM. Records from a prospective database including all consecutive admissions for CRLM between June 2000 and June 2004 were reviewed. The analysis addressed all patients who underwent hepatectomy for primarily resectable CRLM (Group A), or underwent chemotherapy for primarily unresectable CRLM and among these, particularly the patients who were finally resected after downsizing of CRLM (Group B). There were 60 primarily resected patients (Group A). Forty-two other patients underwent chemotherapy; after an average of nine courses, 18 of them (42.8%) with significantly downsized lesions were explored and 15 (35.7%, Group B) were resected, whereas three had peritoneal metastases. Group B differed from Group A for a significantly higher rate of synchronous CRLM upon diagnosis of colorectal cancer, a larger size of CRLM upon evaluation in our center, and a lower rate of major hepatectomies (20.0% vs. 51.6 %) at surgery. No patient in Group B had positive margins of resection. Operative mortality was nil and morbidity was 20.0% in both groups. In Group B vs. Group A median survival after hepatectomy was 46 vs. 47 months (n.s), 3-year survival rate was 73% vs. 71% (n.s.), disease-free survival rate was 31% vs. 58% (p = 0.04) and, at a median follow-up of 34 months, tumor recurrence rate was 53.3% vs. 28.3% (n.s.). Four out of the eight Group B patients with recurrence underwent a re-resection, and were alive at 9 to 67 months after the first resection. These results show that in about one-third of the patients with primarily unresectable CRLM, downsizing of the lesions by chemotherapy (FOLFIRI protocol) permitted a subsequent curative resection. In these patients, operative risk and survival did not differ from the figures observed in primarily resectable patients and, in spite of a lower disease-free survival with more frequent recurrence, re-resection still represented a valid option to continue treatment. Presented at the 2005 Surgical Spring Week AHPBA Meeting (April 14–17, 2005, Fort Lauderdale, Florida).