Anatomical bi- and trisegmentectomies as alternatives to extensive liver resections

Liver resection for hepatocellular carcinoma

The indications and the results for liver resection for hepatocellular cancer (HCC) depend on the stage of the tumor at diagnosis, the functional reserve of the liver, and the use of suitably adapted surgical techniques. This article briefly discusses liver resection for HCC in patients who do not have chronic liver disease and then discusses liver resection for HCC in patients who have chronic liver disease.

Central bisectionectomy for centrally located hepatocellular carcinoma

BACKGROUND

Central bisectionectomy, which involves the removal of the central hepatic segments (IVA, IVB, V, VIII) for hepatocellular carcinoma (HCC), is performed to reduce the volume of resected liver and to overcome the problem of insufficient future residual volume.

METHODS

Twenty-seven patients with HCC underwent central bisectionectomy from January 1998 to April 2007 in one hospital. The surgical techniques, clinicopathological characteristics and outcomes were reviewed.

RESULTS

The median operating time was 330 min. Twelve patients developed postoperative complications and two died. The most common complication, occurring in five patients, was bile duct injury leading to biloma or bile leakage. Median follow-up was 19.1 (range 1.4-102.2) months and eight patients developed a recurrence. Twenty-four patients were alive at the time of writing.

CONCLUSION

Although biliary complications occur somewhat frequently, central bisectionectomy in centrally located HCC can be performed safely to preserve liver volume.

Cholangiocellular carcinoma--the role of caudate lobe resection and mesohepatectomy

BACKGROUND

The surgical treatment of perihilar cholangiocellular carcinoma (CCC) is challenging due to the adjacency of the tumor to the hilar vessels, major hepatic veins, bile ducts, and the inferior vena cava. Additionally, the tumour frequently infiltrates the parenchyma of the caudate lobe or/and invades its bile ducts.

CONSENSUS STATEMENTS

Negative margin caudate hepatectomy is rarely feasible. Isolated partial or complete caudate lobe resection is an oncologically inadequate procedure. Extended hepatectomies in combination with caudate lobectomy can provide prolonged survival, even in patients with advanced CCC. Mesohepatectomy is an oncologically adequate procedure for selected patients with CCC and compromised liver function. The procedure is technically demanding; however, it lowers the risk of postoperative liver failure.

Systematic extended right posterior sectionectomy: a safe and effective alternative to right hepatectomy

BACKGROUND

A surgical approach based on ultrasound-guided hepatectomy might minimize the need for major resection, whose rates of morbidity and mortality are not negligible. Right hepatectomy (RH) is traditionally performed in cases of vascular invasion of the right hepatic vein with multiple tumors in the right posterior section, and/or of the right posterior portal branch (P6-7) with tumor in contact with right anterior portal branch (P5-8). We herein describe an alternative approach to RH consisting in ultrasound-guided systematic extended right posterior hepatic sectionectomy (SERPS).

METHODS

Among 207 consecutive patients who underwent hepatectomies, 21 (10%) underwent SERPS. Median age was 67 years (range, 48-79). There were 13 men and 8 women. Ten (48%) patients had hepatocellular carcinoma; 11 (52%) had colorectal liver metastases. Median tumor number was 2 (range, 1-15); median tumor size was 4.5 cm (range, 2.5-20). Ten (48%) patients had cirrhosis, 8 (38%) had steatosis, and 3 (16%) had normal liver. Surgical strategy was based on tumor-vessels relationship at intraoperative ultrasonography (IOUS) and on findings at color-Doppler IOUS.

RESULTS

In-hospital and 90-days mortality were nil. Major and minor morbidity occurred in 3 (14%) and 2 (9.5%) patients, respectively. No patients were reoperated because of complications. Blood transfusions were given to 2 (9.5%) patients. After a median follow-up of 21 months, no local recurrence was observed.

CONCLUSIONS

IOUS-guided SERPS is feasible, safe, and effective. It should be applied whenever possible as alternative resection to RH to maximize liver parenchymal sparing.

Extraparenchymal control of hepatic veins during mesohepatectomy

BACKGROUND

Bleeding is the most relevant operative risk during mesohepatectomy because of the wideness of the resection surfaces and the exposure of main intrahepatic vascular structures. Preliminary extraparenchymal exposure of the main hepatic veins, with the possibility of clamping them in association with the Pringle maneuver, and the maintenance of a low central venous pressure during mesohepatectomy, can contribute to substantially reducing operative bleeding.

STUDY DESIGN

We report the results obtained in 18 mesohepatectomies, performed for liver metastases (13 patients) and for hepatocellular carcinoma (5 patients). Liver resection was performed without preliminary exposure of the main hepatic veins in nine patients (group A) and with preliminary looping of the main hepatic veins in nine patients (group B), without complications related to the maneuver.

RESULTS

Intermittent pedicle clamping was used in all patients; in six patients in group B (66.7%), clamping of the main hepatic veins was also performed (mean duration, 37 minutes; range 16 to 68 minutes). Intraoperative blood transfusions were needed in 5 patients (5 of 18, 27.8%): 4 belonged to group A (44.4%) and 1 to group B (11.1%). Mortality was nil and morbidity was 33.3%, involving four patients in group A and two in group B (none related to the exposure, looping, and clamping of the main hepatic veins).

CONCLUSIONS

Preliminary control of the main hepatic veins is a safe maneuver. During mesohepatectomy, clamping of these veins, associated with pedicle clamping, is effective in reducing operative bleeding. In our patients, this resulted in a low blood transfusion rate, similar to that of classic major hepatectomies, despite the higher complexity of mesohepatectomy.

Central hepatectomy: the golden mean for treating central liver tumors?

The treatment of patients with central liver tumors involving segments 4, 5 and 8 is a difficult clinical problem. These tumors often straddle Cantlie's line and involve parts of both lobes of the liver. The traditional management of such tumors is to perform either an extended right or an extended left hepatectomy. However, extended hepatectomies are associated with greater morbidity and mortality, mainly due to increased risk of postoperative liver failure. Central hepatectomy (or mesohepatectomy) may be superior to extended hepatectomy, because it conserves more liver parenchyma. However, the operation can be tedious and may result in increased blood loss, and was therefore infrequently used. Recommendations for its application for centrally located tumors are not clear. The aim of our study is to evaluate the evidence supporting central hepatectomy as a safe procedure for the management of central hepatic tumors, and to describe the effectiveness of central hepatectomy compared to extended hepatectomy. We present herein two patients who underwent central hepatectomy and systematically review the English literature until December 2006. We found 13 studies of multisegmental (> or = 2 segments) central liver resection that included at least four patients. Only three retrospective non-randomized studies have looked at central hepatectomy in comparison to lobar or extended hepatectomy, and no clear consensus emerges. To date, there is insufficient evidence to categorically state that central hepatectomy is superior to extended hepatectomy, thus the use of all approaches can be justified. However, if central hepatectomy can be performed without excessive blood loss, then it should be preferred, as it is less extensive and results in greater functional remnant liver. Additionally, it would clearly be superior in patients with cirrhosis.

Randomized clinical trial of radiofrequency-assisted versus clamp-crushing liver resection

BACKGROUND

Surgical resection remains the treatment of choice for primary and secondary liver cancer. Complications are mainly related to blood loss. Radiofrequency-assisted liver resection (RF-R) has been proposed for parenchymal division as an alternative to clamp crushing in order to reduce blood loss.

METHODS

Fifty patients (median age 62 (range 30-82) years) undergoing hepatectomy were randomized to RF-R (24 patients) or the clamp-crushing method (26). In the RF-R group the resection plane was precoagulated by multiple insertion of a planar triple-cooled radiofrequency ablation needle, and then the parenchyma was sectioned using a scalpel.

RESULTS

The two groups were well matched in terms of age, sex, liver disease and type of resection. There were no deaths. Eight in the RF-R group developed complications (abscess in six, biliary fistula in three and biliary stenosis in one) compared with none of those who had resection by the crush method (P < 0.001). Two patients with cirrhosis in each group developed decompensation. Blood transfusion was required in eight of 24 patients in the RF-R group and 13 of 26 in the clamp-crushing group (P = 0.079).

CONCLUSION

RF-R allows parenchymal resection in a clean surgical field but is associated with a higher rate of postoperative complications than the clamp-crushing technique.

Ultrasonographically guided surgical approach to liver tumours involving the hepatic veins close to the caval confluence

BACKGROUND

Intraoperative ultrasonography (IOUS) may allow a more conservative procedure in patients with liver tumours involving a hepatic vein at the caval confluence. The aim of this study was to determine whether IOUS and colour Doppler IOUS might reduce the rate of major hepatectomy and vascular reconstruction in patients with such tumours.

METHODS

Of 133 consecutive patients with a liver tumour who underwent hepatectomy, 22 had involvement of a hepatic vein at the caval confluence. The surgical strategy employed was determined by IOUS findings of the relationship between the tumour and hepatic vein, the presence of accessory veins, and portal flow as measured by colour Doppler IOUS following clamping of the hepatic vein to be resected. Mortality, morbidity, major resection, hepatic vein reconstruction and local recurrence rates were evaluated.

RESULTS

There were no hospital deaths and only one patient suffered major morbidity. Although hepatic vein resection was performed in 15 patients, only two underwent major hepatectomy and none had vascular reconstruction. No patients had tumour recurrence at a mean follow-up of 23 months.

CONCLUSION

IOUS allowed sparing of the liver parenchyma without tumour recurrence in most patients with a tumour involving a hepatic vein at the caval confluence, avoiding more extensive hepatectomy or vascular reconstruction.

Intrahepatic Glissonian access for segmental liver resection in cirrhotic patients

The main goal of segmental technique is to preserve the maximum amount of liver parenchyma. Liver-preserving techniques are especially important for patients with hepatocellular carcinoma and cirrhosis. We report the technique for segmental liver resection in cirrhotic patients and detail technical difficulties and immediate surgical outcome. For right segmental liver resections the intrahepatic access is performed through small incisions around the hilar plate. Left segmental resection technique also consists of small incisions following specific anatomic landmarks. Nineteen cirrhotic patients underwent segmental liver resections. A blood transfusion was required in 2 patients. No patient experienced major bleeding from the liver incisions made for intrahepatic access. The median hospital stay was 5 days. No surgical mortality occurred. The intrahepatic access technique allows individual resections of liver segments and is feasible even in cirrhotic patients. Knowledge of segmental liver resection techniques is an essential armamentarium in the modern era of liver surgery.

Surgery for hepatocellular carcinoma in patients with chronic liver disease

Several options exist

Laparoscopic liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: midterm results and perspectives

OBJECTIVE

Report the midterm results of laparoscopic resection for hepatocellular in chronic liver disease (CLD).

SUMMARY BACKGROUND DATA

Surgical resection for hepatocellular carcinoma (HCC) in chronic liver disease (CLD) remains controversial because of high morbidity and recurrence rates. Laparoscopic resection of liver tumors has recently been developed and could reduce morbidity.

METHODS

From 1998 to 2003, patients with HCC and CLD were considered for laparoscopic liver resection. Inclusion criteria were chronic hepatitis or Child's A cirrhosis, solitary tumor < or =5 cm in size, and location in peripheral segments of the liver. Mortality, morbidity, recurrence rates, and survival were analyzed.

RESULTS

A total of 27 patients were included. Liver resections included anatomic resection in 17 cases and non anatomic resection in 10. Seven conversions to laparotomy (26%) occurred for moderate hemorrhage in 5 cases and technical difficulties in 2 cases. Mortality and morbidity rates were 0% and 33%, respectively. Postoperative ascites and encephalopathy occurred in 2 patients (7%) who both had undergone conversion to laparotomy. Mean surgical margin was 11 mm (range, 1-47 mm). After a mean follow-up of 2 years (range, 1.1-4.7), 8 patients (30%) developed intrahepatic tumor recurrence of which one died. Treatment of recurrence was possible in 4 patients (50%), including orthotopic liver transplantation, right hepatectomy, radiofrequency ablation, and chemoembolization in 1 case each. There were no adhesions in the 2 reoperated patients. Overall and disease-free 3-year survival rates were 93% and 64%, respectively.

CONCLUSION

Our study shows that laparoscopic liver resection for HCC in selected patients is a safe procedure with very good midterm results. This approach could have an impact on the therapeutic strategy of HCC complicating CLD as a treatment with curative intent or as a bridge to liver transplantation.

"Radical but conservative" is the main goal for ultrasonography-guided liver resection: prospective validation of this approach

BACKGROUND

Despite higher blood loss, morbidity, and mortality, rate of major resection is still high in most surgical institutions because of fear of incomplete tumor removal. To verify whether intraoperative ultrasonography (IOUS) minimizes the rate of major hepatectomies while maintaining treatment radicality, we have prospectively validated our policy, based on extensive use of IOUS resection guidance.

STUDY DESIGN

Ninety-three consecutive patients with liver tumors were prospectively enrolled. There were 61 men and 32 women with a mean age of 65.6 years. Fifty-nine patients had hepatocellular carcinoma and 34 had colorectal cancer liver metastases. Surgical strategy was based on the relationship between the tumor and intrahepatic vascular structures at IOUS. Rates of major and minor resection, mortality, morbidity, and rate of local recurrences were evaluated.

RESULTS

There was no hospital mortality; major morbidity occurred in 2.2% of patients and minor complications in 17%. Six (6.5%) patients required blood transfusion. Major resections (two or more segments) were accomplished in 14 patients (15%), and 5 (5.4%) patients had more than three segments removed. Major vascular invasion was present in 16 patients (17%), and contact without infiltration with major vessels was present in another 16; part of the wall of the inferior vena cava was resected in 1 patient. Surgical clearance was achieved in all patients without local recurrence at a mean followup of 18 months (median 13, range 6 to 52 months).

CONCLUSIONS

This study shows that liver operations performed under IOUS guidance are safe and radical and reduce need for major hepatectomies.

Bisegmentectomy 7–8 as alternative to more extensive liver resections

BACKGROUND

Preservation of hepatic parenchyma should be attempted whenever possible in order to reduce the risk of liver failure and increase the chance to re-resect the recurrence.

STUDY DESIGN

The presence of a lesion in segments 7-8 infiltrating the right hepatic vein is usually an indication for right hepatectomy. If a thick inferior right hepatic vein is seen, a bisegmentectomy 7-8 can be performed. We review our experience with this uncommon liver resection.

RESULTS

In 11 of 332 patients with colorectal liver metastases, a lesion was localized in segments 7-8 infiltrating the right hepatic vein. Six underwent resection of segments 7-8. The mean estimated rate of remnant liver volume (segments 2-4 plus caudate lobe) was 23.7%; 4 patients had neoadjuvant chemotherapy. Intraoperative mean blood loss was 200 mL without transfusions; no patients developed postoperative liver failure, and there was no in-hospital mortality. Surgical margin was negative in all patients. Median survival was 25 months, with 3 patients alive and disease-free. One patient with an intrahepatic recurrence underwent re-resection.

CONCLUSIONS

Bisegmentectomy 7-8 is an uncommon but safe procedure that allows curative resections without unnecessary sacrifice of functional parenchyma.

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.