Anterior transhepatic approach for isolated resection of the caudate lobe of the liver

A multicenter validation study for determining the condition of nonanatomical or minor anatomical hepatectomies satisfying technical difficulty of current high-level hepatectomy certificated by the Japanese Society of Hepato-Biliary-Pancreatic Surgery

BACKGROUND

The current high-level hepatectomy (HLH) is certified by the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS), comprising only anatomical hepatectomies above Couinaud's segmentectomy. This multicenter study aimed to identify the conditions of non-HLH that satisfy equivalent technical difficulties to HLH.

METHODS

Between 2018 and 2021, 595 first open hepatectomies without biliary reconstruction (374 HLHs and 221 non-HLHs) were performed in the five institutions. Non-HLHs belonging to at least one of the three conditions; depth of hepatectomy ≥5 cm, number of resections ≥3 locations and at least one location with a depth of hepatectomy ≥3 cm, and hepatectomy involving the paracaval portion of the caudate lobe was proposed as the candidate for difficult non-HLH. The technical difficulty was estimated by the operative time and blood loss.

RESULTS

Difficult non-HLHs were neither associated with shorter operative time (373 min vs. 354 min, p = .184) nor lesser blood loss than those with HLHs (503 mL vs. 436 mL, p = .126). Postoperative complications such as Clavien-Dindo classification grade III or more were not significant between the two groups (18.6% vs. 13.4%, p = 0212).

CONCLUSIONS

Difficult non-HLHs were associated with no lesser technical difficulty than those with HLH.

Modified median hepatic fissure approach for resection of liver tumours located in the angle between the root of the middle and right hepatic veins

Background

Liver tumours between the root angle of the middle and right hepatic veins are a special type of liver segment VIII tumour. In this study, we designed a modified median hepatic fissure approach to remove these tumours. The safety and effectiveness of the approach were evaluated.

Materials and methods

From April 2015 to November 2019, 11 patients with liver tumours between the angle of the middle and right hepatic veins underwent this modified median hepatic fissure approach. We retrospectively analysed data from the perioperative periods of these 11 patients, including general condition, operation time, intraoperative bleeding, and postoperative complications. Disease-free survival and overall survival were assessed.

Results

Of the 11 patients, 9 patients had primary hepatocellular carcinoma and 2 had colorectal liver metastases. The average intraoperative blood loss was 285 mL (150–450 mL). Two patients developed postoperative bile leakage, but there were no significant serious complications, such as intraabdominal bleeding and liver failure, in any of the patients. The liver function returned to the normal range on the 5th day after surgery. Of the 11 patients, 5 have survived for more than 3 years (45.5%), and 4 have been disease-free for more than 3 years (36.3%).

Conclusions

For liver tumours between the root angle of the middle and right hepatic veins, the modified median hepatic fissure approach is a safe and feasible method.

Parenchymal-sparing approaches for resection of tumors located in the paracaval portion of the caudate lobe of the liver-utility of limited resection and central hepatectomy

PURPOSE

Resection of liver cancer involving the paracaval portion (PC) of the caudate lobe is challenging because the PC is located deepest in the liver. This study aimed to elucidate the utility of two parenchymal-sparing approaches of limited resection and central hepatectomy for resecting tumors located in the PC.

METHODS

In 2018 and 2020, 12 out of 143 patients underwent hepatectomy for tumors located in the PC of the liver. In six patients, limited resection (LR) of the PC after full mobilization of the liver off the inferior vena cava (IVC) was performed for tumors excluding the hilar plate or large hepatic veins (large HVs), including major hepatic veins or thick short hepatic veins. In six patients, central hepatectomy (CH) using liver tunnel was performed for tumors involving or close to the hilar plate and/or large HVs.

RESULTS

During CH, the surgical view of the cranial side of the hilar plate was wide enough to perform combined resection of the large HVs in front of the IVC. Five of the six CHs were performed with resection of the LHVs. No LRs were accompanied with resection of the LHVs. The CH was associated with longer Pringle's time (76 min vs. 29.5 min, p = 0.015) and blood loss (1104 ml vs. 370 ml, p = 0.041). The preserved liver parenchyma volumes were 82% and 95% of the total liver volume after CH and LR, respectively.

CONCLUSION

Our parenchymal-sparing approach for resection of liver cancer located in the PC is feasible for curative resection.

Laparoscopic anterior hepatic transection for resecting lesions originating in the paracaval portion of the caudate lobe (with videos)

BACKGROUND

The paracaval portion of the caudate lobe is located in the core of the liver. Lesions originating in the paracaval portion often cling to or even invade major hepatic vascular structures. The traditional open anterior hepatic transection approach has been adopted to treat paracaval-originating lesions. With the development of laparoscopic surgery, paracaval-originating lesions are no longer an absolute contraindication for laparoscopic liver resection. This study aimed to evaluate the safety and feasibility of laparoscopic anterior hepatic transection for resecting paracaval-originating lesions.

METHODS

This study included 15 patients who underwent laparoscopic anterior hepatic transection for paracaval-originating lesion resection between August 2017 and April 2020. The perioperative indicators, follow-up results, operative techniques and surgical indications were retrospectively evaluated.

RESULTS

All patients underwent laparoscopic anterior hepatic transection for paracaval-originating lesion resection. The median operation time was 305 min (220-740 min), the median intraoperative blood loss was 400 ml (250-3600 ml), and the median length of postoperative hospital stay was 9 days (5-20 days). No conversion to laparotomy or perioperative deaths occurred. Six patients had Clavien grade III-IV complications (III/IV, 5/1). Two patients developed tumor recurrence after 13 months and 8 months.

CONCLUSION

Although technically challenging, laparoscopic anterior hepatic transection is still a safe and feasible procedure for resecting paracaval-originating lesions in select patients.

Laparoscopic caudate lobectomy: a multicenter, propensity score-matched report of safety, feasibility, and early outcomes

BACKGROUND

Caudate lobectomy via laparoscopic surgery has rarely been described. This multicenter, propensity score-matched study was performed to assess the safety and efficacy of laparoscopic caudate lobectomy (LCL).

METHODS

A multicenter retrospective study was performed including all patients who underwent LCL and open caudate lobectomy (OCL) in four institutions from January 2013 to December 2018. In total, 131 patients were included in this study and divided into LCL (n = 19) and OCL (n = 112) groups. LCLs were matched to OCLs (1:2) using a propensity score matching (PSM) based on nine preoperative variables, including patient demographics and tumor characteristics. The pathological results, perioperative and postoperative parameters, and short-term outcomes were compared between the two groups.

RESULTS

After PSM, there were 18 and 36 patients in the LCL and OCL groups, respectively. Baseline characteristics were comparable after matching. LCL was associated with less blood (100 vs. 300 ml, respectively; P < 0.001) and a shorter postoperative stay (6.0 vs 8.0 days, respectively; P = 0.003). Most patients' resection margins were > 10 mm in the LCL group (P = 0.021), and all patients with malignancy in both groups achieved R0 resection. In terms of early postoperative outcomes, the overall morbidity rate was identical in each group (11.1% vs. 11.1%, respectively; P = 1.000). No mortality occurred in either group.

CONCLUSIONS

Laparoscopy is a feasible choice for resection of tumors located in the caudate lobe with acceptable perioperative results.

Technical notes on pure laparoscopic isolated caudate lobectomy for patient with liver cancer

BACKGROUND

The advantages of laparoscopic liver resection become more obvious as evidence on its long-term outcome has emerged. Compared to open resection, there is no difference in term of overall survival. Many reports showed that the hospital stay was shorter and blood loss was less when laparoscopic hepatectomy was used. However, laparoscopic approach for caudate lobe resection remains a challenging procedure. The close proximity to inferior vena cava (IVC) and hepatic vein make this procedure extra difficult. This paper will demonstrate the use of pure laparoscopic approach for a patient with caudate lobe liver metastasis. Haemostasis by intracorporal suturing is safely performed when bleeding is encountered from the IVC.

METHOD

The patient was a 54-year-old lady who had carcinoma of the rectum with laparoscopic anterior resection performed. She was found to have a 2 cm lesion in the left caudate lobe of the liver on follow-up. Her platelet count was only 120×10⁹/L. Pure laparoscopic resection of the caudate lobe was performed as shown in the video.

RESULTS

The operation last for 180 minutes. Blood loss was 220 mL and no blood transfusion was required. She resumed diet on the next day and was discharged 3 days after the operation. Histopathological examination showed 2 cm colorectal liver metastasis with a clear margin. Contrast CT scan performed 1 year after the operation showed no recurrence of the disease.

CONCLUSIONS

Laparoscopic approach for caudate lobe resection is a feasible option. It can be performed to patients in center by surgeons with experience in both hepatobiliary and laparoscopic skills.

Anterior hepatic parenchymal transection for complete caudate lobectomy to treat liver cancer situated in or involving the paracaval portion of the caudate lobe

BACKGROUND

Complete caudate lobectomy using the anterior hepatic parenchymal transection approach is a proper but technically demanding operation for tumors situated in or involving the paracaval portion of the caudate lobe. This study was intended to share our experience on this operation.

METHOD

Forty-nine consecutive patients who received complete caudate lobectomy using the anterior hepatic parenchymal transection approach were studied. The clinicopathologic and perioperative data, complications, and survival were analyzed.

RESULTS

Of the 49 patients, 15 (30.6 %) received isolated complete caudate lobectomy and 34 (69.4 %) received complete caudate lobectomy associated with segmentectomy IV. The median tumor size was 7.3 cm (2.4-18.0 cm), the operating time was 200 min (120-370 min), and the operative blood loss was 700 ml (200-3000 ml). The postoperative complication rate was 36.7 %. There was no perioperative death. Patients in the associated complete caudate lobectomy group had larger tumors (P<0.001), higher platelet counts (P=0.033), shorter operation time (P=0.004), and less patients with residual tumor (P=0.03) than those in the isolated complete caudate lobectomy group. There were no significant differences in cirrhosis, surgical resection margin, blood loss, postoperative complications, and prognosis between the two groups.

CONCLUSION

Complete caudate lobectomy using the anterior hepatic parenchymal transection approach was technically feasible and safe for patients with tumors situated in or involving the paracaval portion of the caudate lobe. Associated resection of segment IV can be used to facilitate the surgery and decrease the chance of local residual tumor.

Development and clinical usefulness of the liver hanging maneuver in various anatomical hepatectomy procedures

PURPOSE

To assess the clinical application and usefulness of the liver hanging maneuver (LHM), proposed by Belghiti, for major hepatectomy, including its (1) historical development, (2) usefulness and application and (3) advantages and disadvantages, by reviewing the English literature published during the period 2001-2014.

RESULTS

In major hepatic transection via the anterior approach, the deep area of transection around the vena cava is critical with regard to bleeding during right hemi-hepatectomy. Belghiti and other investigators identified avascular spaces that are devoid of short hepatic veins at the front of the vena cava and behind the liver. Forceps can be inserted into this space easily and then maneuvered to lift the liver using hanging tape. This procedure, termed LHM significantly reduces intraoperative blood loss and the transection time during right hemi-hepatectomy. LHM has been used in various anatomical hepatectomy procedures worldwide, including laparoscopic hepatectomy. The use of LHM markedly improves the amount of intraoperative blood loss, operative time and postoperative outcome.

CONCLUSIONS

We conclude that the application of LHM is an important development in the field of liver surgery, although a further evaluation of its true impact on clinical outcomes is necessary.

Improved anterior hepatic transection for isolated hepatocellular carcinoma in the caudate

BACKGROUND

One of the best treatments for isolated hepatocellular carcinoma in the caudate lobe is major hepatectomy with caudate lobectomy, but it is not suitable for patients with poor liver function reserve. Isolated caudate lobectomy, which is a very difficult operation, is thus an alternative option.

METHODS

Here we report an isolated caudate lobectomy with an anterior approach in the treatment of a large hepatocellular carcinoma with underlying cirrhosis, with focus on the technical aspects.

RESULTS

In the operation, both the left and right lobes of the liver were mobilized. Hepatotomy was done along the round ligament where parenchymal transection was minimal. After exposure of the left and middle hepatic veins and the hilar plate, the caudate lobe and the tumor were resected en bloc with a 5-mm margin.

CONCLUSION

Isolated caudate lobectomy can be performed safely with this anterior approach on patients with poor liver function reserve.

Isolated caudate lobectomy with pancreatoduodenectomy for a bile duct cancer

BACKGROUND

In patients with distal bile duct cancer involving the hepatic hilus, a major hepatectomy concomitant with pancreatoduodenectomy (HPD) is sometimes ideal to obtain a cancer-free resection margin. However, the surgical invasiveness of HPD is considerable.

PATIENTS AND METHODS

We present our treatment option for patients with distal bile duct cancer showing mucosal spreading to the hepatic hilum associated with impaired liver function. To minimize resection volume of the liver, an isolated caudate lobectomy (CL) with pancreatoduodenectomy (PD) using an anterior liver splitting approach is presented. Liver transection lines and bile duct resection points correspond complete with our standard right and left hemihepatectomies with CL for perihilar cholangiocarcinoma.

RESULTS

Total operation time was 765 min, and pedicle occlusion time was 124 min, respectively. Although the proximal mucosal cancer extension was identified at both the right and the left hepatic ducts, all resection margins were negative for cancer.

CONCLUSIONS

Isolated CL with PD is an alternative radical treatment option for bile duct cancer patients with impaired liver function.

Isolated caudate lobe (Spiegel lobe) resection for hepatoblastoma. Is it enough to achieve a sufficient resection margin? A case report

BACKGROUND

Hepatoblastoma arising from and limited to the caudate lobe is an extremely rare clinical entity. The object of this case report is to present a case of isolated caudate lobe resection due to hepatoblastoma originating in the caudate lobe.

METHODS

The patient was an 18-month-old male who was admitted with a huge tumor located in the left hepatic lobe. The histological diagnosis was fetal type of hepatoblastoma. The patient received 4 cycles of preoperative and 2 cycles of postoperative chemotherapy.

RESULTS

During surgical exploration, a well-defined, exophytic tumor originating in the caudate lobe was found. Isolated caudate lobe (Spiegel lobe) resection was performed. The intra- and postoperative course was uneventful. Surgical margins were negative for tumor. The patient remains alive with no signs of recurrence 15 months after surgery.

CONCLUSIONS

Isolated caudate lobe resection is one of the most challenging procedures in liver surgery. Despite the technical difficulties and high complications risk, isolated caudate lobectomy can be performed successfully in children. It needs to be noted that in the reported case, preoperative chemotherapy shrunk the tumor and largely facilitated its resection.

Prognosis of patients undergoing hepatectomy for solitary hepatocellular carcinoma originating in the caudate lobe

BACKGROUND

Operative and nonoperative treatment for hepatocellular carcinoma (HCC) originating in the caudate lobe is regarded as challenging because of its deep location in the liver and possibly worse prognosis than HCC in other sites in the liver. The objective of this study is to investigate the clinicopathologic factors and survival of patients who underwent hepatectomy for solitary HCC originating in the caudate lobe.

METHODS

A retrospective review of 783 patients who underwent curative hepatectomy for solitary HCC between 1988 was performed. Clinicopathologic factors and survival rate of 46 (5.9%) patients with HCC originating in the caudate lobe were compared with those of 737 (94%) patients with HCC arising in other sites.

RESULTS

The clinical backgrounds of patients with HCC in the caudate lobe and in other sites were comparable. Hepatectomy for HCC in the caudate lobe was associated with greater operative time and blood loss than for HCC in other sites of the liver. Pathologically, HCC in the caudate lobe was associated with less frequent intrahepatic metastasis, lesser operative margins, and more frequent tumor exposure than HCC in other sites. Overall and disease-free 5-year survival rates of the 46 patients with solitary HCC in the caudate lobe were 76% and 45%, respectively; no significant difference was observed in the overall or disease-free survival rates between the 2 groups (P = .07 and P = .77, respectively). Resection of HCC in the paracaval portion of the caudate lobe (n = 27) was associated with more frequent anatomic resection, greater operative time and blood loss, and a lesser operative margin than HCC in the Spiegel lobe or caudate process (n = 19).

CONCLUSION

Resection for HCC in the caudate lobe, especially in the paracaval portion, remains technically demanding. The prognosis of patients with solitary HCC in the caudate lobe, however, was as good as that of patients with solitary HCC in other sites in the liver.

Isolated caudate lobe resection for hepatic tumor: surgical approaches and perioperative outcomes

BACKGROUND

Caudate lobe of the liver is relatively inaccessible because of its deep location and lying between the major vascular structures. Therefore, isolated caudate lobe resection (ICLR) is a much challengeable operation.

METHODS

Review of prospectively collected data from patients who underwent ICLR for hepatic tumor.

RESULTS

Forty-six patients (mean age 46.8 years) underwent ICLR for malignant (39 cases) and benign (7 cases) hepatic tumors. ICLRs were performed by 3 different approaches and in different ways of hepatic vascular control: without any vascular control in 7 patients, under Pringle maneuver in 26 patients, and under sequential inflow and outflow vascular occlusion in 13 patients. There were no perioperative deaths, and the postoperative complication rate was 8.7% (4/46). The mean operative time was 174.5 +/- 44.3 minutes and the mean estimated intraoperative blood loss was 504.4 +/- 356.2 mL.

CONCLUSIONS

ICLR is a technically demanding but safe procedure. Choice of surgical approaches and ways of hepatic vascular control should be based on tumor location and surgeons'experience.

Caudate lobe resection: an Egyptian center experience

BACKGROUND DATA

Hepatectomy is a technically challenging surgery, and of all aspects of hepatic resection, caudate lobe resection is the most difficult. Knowledge of the anatomy of the caudate lobe is necessary to achieve safe caudate lobe resection.

METHODOLOGY

Hospital records of 54 patients, who had caudate lobe resection in our center from January 2000 to August 2007, were retrieved. The demographic data, clinicopathological features, and perioperative events were extracted and analyzed.

RESULTS

Out of a total of 500 patients who had various forms of hepatic resection during the period in question, only 54 had caudate lobe resection (10.8%). Isolated caudate lobe resection (ICLR) was performed in 16 (29.6%) patients while the remainder had caudate lobe resection as a part of a major hepatectomy. Indications for hepatectomy in patients with ICLR include hepatocellular carcinoma, primary hepatic carcinoid tumor, cavernous hemangioma, and adenoma. Mean operative time for ICLR was 230 +/- 50 min while it was 240 +/- 50 min for right hepatectomy and 245 +/- 55 min for left hepatectomy. The associated mean blood loss was 1200 +/- 200, 1300 +/- 350, and 1350 +/- 350 ml, respectively. None of these were statistically significant. In patients who had ICLR, there was no mortality while three patients developed postoperative complications (bile leak in two patients and one patient with wound infection). Various forms of perioperative complications were noticed in six patients. All these patients, who also showed 7.8% mortality, had major hepatectomy.

CONCLUSIONS

Caudate lobe resection is a technically challenging procedure. Isolated caudate lobe resection is a safe procedure with good outcome in well selected patients. It is, however, associated with increased perioperative risks when associated with major hepatectomy.

Surgery for hepatocellular carcinoma located in the caudate lobe

BACKGROUND

Surgery remains difficult for hepatocellular carcinoma (HCC) originating in the caudate lobe. Our objective was to evaluate the safety and problems associated with caudate lobectomy combined with other types of hepatectomy.

METHODS

We performed caudate resection for HCC in 12 patients. Clinical and operative characteristics and survival were analyzed.

RESULTS

Tumors were located in the Spiegel lobe in three patients, the caudate process in six, and the paracaval portion in three. The procedure performed most was isolated partial caudate lobe resection (six patients). Three patients underwent partial caudate lobe resection combined with other hepatectomy, and the remainder underwent total caudate lobe resection combined with other hepatectomy. Tumors of the patients who underwent combined total caudate lobe resection were mainly in the paracaval portion. The median operating time for the six patients who underwent combined resection was 400 min, and their median intraoperative blood loss was 1,683 ml. There were no postoperative complications in patients who underwent combined total caudate lobe resection, except one case of total resection combined with central bisegmentectomy. In that case, the remaining right posterior sector was twisted after liver extraction, causing blockage of the outflow of the right hepatic vein. The overall and recurrence-free survival rates did not differ between the isolated and combined resection groups.

CONCLUSIONS

For removal of HCC located in the caudate lobe, especially the paracaval portion, partial or total caudate lobe resection with other types of hepatectomy contributes to safe, curative surgery if the liver functional reserve and complications associated with surgery are well understood.

Step-by-step isolated resection of segment 1 of the liver using the hanging maneuver

The caudate lobe can be the origin of primary liver tumours or the sole site of liver metastases. This lobe is anatomically divided into 3 parts: Spiegel's lobe (Couinaud's segment 1), paracaval portion (Couinaud's segment 9), and the caudate process. In this series of 4 cases, we provide a step-by-step description of a surgical technique variation that can be applied to resections of lesions localized in segment 1. We believe that other than size, lesion removal in this hepatic anatomic area, which is difficult to perform, can be done more easily using this new approach because it requires minimal mobilization without unnecessary parenchyma transection of other liver parts. Therefore, it reduces the risk of lesions in the inferior vena cava and the middle hepatic vein and respects adequate margins without the use of clamping maneuvers and in an acceptable surgical time.

High dorsal resection for recurrent hepatocellular carcinoma originating in the caudate lobe

Standards that enable surgeons to balance radical operative procedures with functional preservation for recurrent hepatocellular carcinoma (HCC) in the caudate lobe have not yet been established. A 54-year-old man with recurrent HCC originating in the caudate lobe was readmitted to our hospital. The combined resection of the adjacent hepatic parenchyma may have carried a risk of postoperative liver failure. The anterior transhepatic approach may have caused massive bleeding due to the presence of scarring from the previous hepatectomy. Therefore, we performed an isolated total caudate lobectomy, i.e., a "high dorsal resection" as a second hepatectomy. The postoperative course of the patient was uneventful, and there has been no local recurrence 1 year after the repeat hepatectomy. Indeed a "high dorsal resection" is rarely required, but it is still ingenious, and this surgical modality can balance the curability with the hepatic functional reserve even for recurrent caudate HCC in patients with liver cirrhosis.

Anterior hepatic transection for caudate lobectomy

Resection of the caudate lobe (segment I- dorsal sector, segment IX- right paracaval region, or both) is often technically difficult due to the lobe's location deep in the hepatic parenchyma and because it is adjacent to the major hepatic vessels (e.g., the left and middle hepatic veins). A literature search was conducted using Ovid MEDLINE for the terms "caudate lobectomy" and "anterior hepatic transection" (AHT) covering 1992 to 2007. AHT was used in 110 caudate lobectomies that are discussed in this review. Isolated caudate lobectomy was performed on 28 (25.4%) patients, with 11 case (11%) associated with hepatectomy, while 1 (0.9%) was associated with anterior segmentectomy. Complete caudate lobectomy was performed on 82 (74.5%) patients. Hepatocellular carcinoma was observed in 106 (96.3%) patients, while 1 (0.9%) had hemangioma and 3 (2.7%) had metastatic caudate tumors. AHT was used in 108 (98.1%) caudate resections, while AHT associated with a right-sided approach was performed in 2 (1.8%) cases. AHT is recommended for tumors located in the paracaval portion of the caudate lobe (segment IX). AHT is usually a safe and potentially curative surgical option.

Resection of hepatic colorectal metastases involving the caudate lobe: perioperative outcome and survival

PURPOSE

To examine clinical features and outcome of patients who underwent hepatic resection for colorectal liver metastases (LM) involving the caudate lobe.

PATIENTS AND METHODS

Consecutive patients who underwent hepatic resection for LM from May 1990 to September 2004 were analyzed from a multicenter database. Demographics, operative data, pathologic margin status, recurrence, and survival were analyzed.

RESULTS

Of 580 patients, 40 (7%) had LM involving the caudate. Six had isolated caudate LM and 34 had LM involving the caudate plus one or more other hepatic segments. Patients with caudate LM were more likely to have synchronous primary colorectal cancer (63% vs. 36%; P = 0.01), multiple LM (70% vs. 51%; P = 0.02) and required extended hepatic resection more often than patients with non-caudate LM (60% vs. 18%; P < 0.001). Only four patients with caudate LM underwent a vascular resection; three at first operation, one after recurrence of a resected caudate tumor. All had primary repair (vena cava, n = 3; portal vein, n = 1). Perioperative complications (43% vs. 28%) and 60-day operative mortality (0% vs. 1%) were similar (caudate vs. non-caudate LM, both P > 0.05). Pathological margins were positive in 15 (38%) patients with caudate LM and in 43 (8%) with non-caudate LM (P < 0.001). At a median follow-up of 40 months, 25 (64%) patients with caudate LM recurred compared with 219 (40%) patients with non-caudate LM (P = 0.01). Patients with caudate LM were more likely to have intrahepatic disease as a component of recurrence (caudate: 51% vs. non-caudate: 25%; P = 0.001). No patient recurred on the vena cava or portal vein. Patients with caudate LM had shorter 5-year disease-free and overall survival than patients with non-caudate LM (disease-free: 24% vs. 44%; P = 0.02; overall: 41% vs. 58%; P = 0.02).

CONCLUSIONS

Patients who undergo hepatic resection for caudate LM often present with multiple hepatic tumors and tumors in proximity to the major hepatic veins. Extended hepatectomy is required in the majority, although vascular resection is not frequently necessary; when performed, primary repair is usually possible. Despite resection in this population of patients with multiple and bilateral tumors, and despite close-margin and positive-margin resection in a significant proportion, recurrence on the portal vein or vena cava was not observed, and long-term survival is accomplished (41% 5-year overall survival).

Isolated laparoscopic resection of the hepatic caudate lobe: surgical technique and a report of 2 cases

The caudate lobe of the liver, segment 1 (S1), is located between the hepatic hilum and the inferior vena cava. Resection of S1 alone, without sacrificing other parts of the liver, is a surgical challenge. We present 2 cases of isolated laparoscopic resections of hepatic S1. We are the first to describe this laparoscopic technique. Two patients affected by colorectal liver metastases confined to S1 underwent laparoscopic isolated resections of S1 using a left approach. One of them also underwent left lateral segmentectomy. Both interventions were accomplished laparoscopically without conversion. Operative time for the first patient was 150 minutes and that for the second patient was 105 minutes. Blood loss was 200 and 100 mL for the first and second patients, respectively. There were no major intraoperative complications except for a tear in the inferior vena cava in the first patient that was repaired without the need for conversion. The postoperative course was uneventful for both patients. The duration of hospital stay was 10 and 8 days, respectively. The resected margins of the specimens were tumor-free (R0 resections). The 2 patients are alive and disease-free 7 and 5 months after the procedure. Isolated laparoscopic resection of the hepatic caudate lobe can be performed by a highly skilled surgeon, but should be performed only in selected cases.

Anterior approach for major right hepatic resection

We review the history, indications, and latest modifications of the surgical technique of the anterior approach for right hepatectomy for massive tumors. The anterior approach provides a "no-touch" technique in resecting large right-lobe tumors, reduces bleeding volume, decreases the chance of iatrogenic rupture of tumors, and probably prolongs survival.

Vascular control during hepatectomy: review of methods and results

The various techniques of hepatic vascular control are presented, focusing on the indications and drawbacks of each. Retrospective and prospective clinical studies highlight aspects of the pathophysiology, indications, and morbidity of the various techniques of hepatic vascular control. Newer perspectives on the field emerge from the introduction of ischemic preconditioning and laparoscopic hepatectomy. A literature review based on computer searches in Index Medicus and PubMed focuses mainly on prospective studies comparing techniques and large retrospective ones. All methods of hepatic vascular control can be applied with minimal mortality by experienced surgeons and are effective for controlling bleeding. The Pringle maneuver is the oldest and simplest of these methods and is still favored by many surgeons. Intermittent application of the Pringle maneuver and hemihepatic occlusion or inflow occlusion with extraparenchymal control of major hepatic veins is particularly indicated for patients with abnormal parenchyma. Total hepatic vascular exclusion is associated with considerable morbidity and hemodynamic intolerance in 10% to 20% of patients. It is absolutely indicated only when extensive reconstruction of the inferior vena cava (IVC) is warranted. Major hepatic veins/ and limited IVC reconstruction has been also achieved under inflow occlusion with extraparenchymal control of major hepatic veins or even using the intermittent Pringle maneuver. Ischemic preconditioning is strongly recommended for patients younger than 60 years and those with steatotic livers. Each hepatic vascular control technique has its place in liver surgery, depending on tumor location, underlying liver disease, patient cardiovascular status, and, most important, the experience of the surgical and anesthesia team.

Perioperative blood transfusions for the recurrence of colorectal cancer

BACKGROUND

The improvement of renal allograft survival by pre-transplantation transfusions alerted the medical community to the potential detrimental effect of transfusions in patients being treated for cancer.

OBJECTIVES

The present meta-analysis aims to evaluate the role of perioperative blood transfusions (PBT) on colorectal cancer recurrence. This is accomplished by validating the results of a previously published meta-analysis (Amato 1998); and by updating it to December 2004.

SEARCH STRATEGY

Published papers were retrieved using Medline, EMBASE, the Cochrane Library, controlled trials web-based registries, or the CCG Trial Database. The search strategy used was: {colon OR rectal OR colorectal} WITH {cancer OR tumor OR neoplasm} AND transfusion. The tendency not to publish negative trials was balanced by inspecting the proceedings of international congresses.

SELECTION CRITERIA

Patients undergoing curative resection of colorectal cancer (classified either as Dukes stages A-C, Astler-Coller stages A-C2, or TNM stages T1-3a/N0-1/M0) were included if they had received any amount of blood products within one month of surgery. Excluded were patients with distant metastases at surgery, and studies with short follow-up or with no data.

DATA COLLECTION AND ANALYSIS

A specific form was developed for data collection. Data extraction was cross-checked, using the most recent publication in case of repetitive ones. Papers' quality was ranked using the method by Evans and Pollock. Odds ratios (OR, with 95% confidence intervals) were computed for each study, and pooled estimates were generated by RevMan (version 4.2). When available, data were stratified for risk factors of cancer recurrence.

MAIN RESULTS

The findings of the 1998 meta-analysis were confirmed, with small variations in some estimates. Updating it through December 2004 led to the identification of 237 references. Two-hundred and one of them were excluded because they analyzed survival (n=22), were repetitive (n=26), letters/reviews (n=66) or had no data (n=87). Thirty-six studies on 12,127 patients were included: 23 showed a detrimental effect of PBT; 22 used also multivariable analyses, and 14 found PBT to be an independent prognostic factor. Pooled estimates of PBT effect on colorectal cancer recurrence yielded overall OR of 1.42 (95% CI, 1.20 to 1.67) against transfused patients in randomized controlled studies. Stratified meta-analyses confirmed these findings, also when stratifying patients by site and stage of disease. The PBT effect was observed regardless of timing, type, and in a dose-related fashion, although heterogeneity was detected. Data on surgical techniques was not available for further analysis.

AUTHORS' CONCLUSIONS

This updated meta-analysis confirms the previous findings. All analyses support the hypothesis that PBT have a detrimental effect on the recurrence of curable colorectal cancers. However, since heterogeneity was detected and conclusions on the effect of surgical technique could not be drawn, a causal relationship cannot still be claimed. Carefully restricted indications for PBT seems necessary.

Surgical outcome of patients with hepatocellular carcinoma originating in the caudate lobe

BACKGROUND

Hepatocellular carcinoma (HCC) originating in the caudate lobe is rare, and the treatment for this type of carcinoma is difficult because of its unique anatomic location.

METHODS

This retrospective study assessed the surgical outcome of patients with caudate lobe HCC. There were 20 cases of HCC originating in the caudate lobe among 435 patients with primary HCC who underwent hepatic resection in our department from 1990 to 2002. The caudate tumors were located in the Spiegel lobe in 3 patients, the paracaval portion in 15 patients, and the caudate process in 2 patients. Surgical procedures consisted of limited resection of the caudate lobe in 6 patients and extended caudate lobectomy in 14 patients. Recurrence was recognized in 12 patients, including 8 patients with multiple intrahepatic recurrences, 1 with peritoneal dissemination, and 1 with lymph node metastasis.

RESULTS

There was no significant difference in postoperative survival rate between patients who underwent limited resection of the caudate lobe and those who underwent extended caudate lobectomy. Compared with 415 patients with HCC originating in other locations, the 20 patients with caudate lobe HCC showed significantly more intraoperative blood loss (P<.05), longer operation time (P<.0001), and more postoperative complications (P<.005). Intrahepatic recurrence was more frequent in the caudate lobe HCC compared with HCC originating in other locations (40% vs 17.6%; P<.05). There was a significantly poor survival rate in the postoperative patients with caudate HCC (25.9% vs 54.1% for five-year survival; P=.01). Intrahepatic multiple recurrences were frequently recognized in the patients with caudate lobe HCC, indicating no significance for extended caudate lobectomy.

CONCLUSIONS

Because of the relatively poor prognosis in patients with caudate lobe HCC, adjuvant therapy combined with surgical operation should be considered.

Radiofrequency Ablation for the Treatment of Liver Tumors in the Caudate Lobe

PURPOSE

To evaluate the effectiveness of radiofrequency (RF) ablation for liver tumors located in the caudate lobe.

MATERIALS AND METHODS

Ten patients (46-79 years of age; median, 70 y), eight with hepatocellular carcinoma (HCC) and cirrhosis and two with colorectal metastases in the caudate lobe, were treated with 5.8% NaCl tissue-perfused monopolar (n=7) or bipolar (n=3) RF ablation. The median tumor diameter was 41 mm (range, 25-70 mm). Procedures were performed under ultrasound and computed tomography (CT) guidance in eight and two patients, respectively. One month later, the treatment response was assessed by CT.

RESULTS

Transhepatic right intercostal and transomental anterior epigastric routes were used for tumor puncture in eight and two patients, respectively. The entire RF ablation treatment required one or two procedures (median, 1.5), including two to 15 electrode repositionings (median, 6). After RF ablation procedure, one patient experienced jaundice that resolved spontaneously. In one patient, CT follow-up showed asymptomatic segmental biliary duct dilations. Median total hospital stay was 3 days (range, 2-9 d). Complete ablation was achieved in nine of 10 tumors. In one patient, ethanol ablation was necessary to complete RF ablation treatment. After a median follow up of 9.5 months (range, 5-25 mo), three patients remained tumor-free and seven had tumor relapse: two local, four distant, and one mixed. Repeat RF ablation was successfully performed in four cases.

CONCLUSION

RF ablation of liver tumors located in the caudate lobe is effective despite the deep location of tumors and the vicinity of major vessels.

Surgical strategy for hepatocellular carcinoma originating in the caudate lobe

BACKGROUND

The prognosis of hepatocellular carcinoma originating in or mainly involving the caudate lobe (caudate HCC) is generally poor. We reviewed the clinicopathologic findings of patients who underwent liver resection of caudate HCC and correlated the outcome with the surgical strategy.

METHODS

Records of 402 patients who underwent liver resection for HCC were reviewed. The patients were divided into 2 groups. One group consisted of 15 patients who underwent liver resection for caudate HCC. The other group included 387 patients with HCC in a site other than the caudate lobe.

RESULTS

Anatomic resection of Couinaud segment I or IX (a partial caudate lobectomy), conforming to portal anatomy, was performed in 13 patients with caudate HCC, and segmentectomies of segments I and IX (a total caudate lobectomy) were performed in 2 patients with caudate HCC. The incidence of postoperative complications was similar in the caudate HCC group and HCC in other sites group, with no operative deaths in the caudate HCC group. Tumor-free survival and cumulative survival were similar in the 2 groups. However, among patients with caudate HCC, tumor-free and cumulative survival were lower in patients with than without microscopic portal venous involvement (P<.01).

CONCLUSIONS

Partial caudate lobectomy (anatomic resection of segment I or IX) along the portal system is an appropriate procedure for caudate HCC, especially in patients with impaired liver function or a small HCC. Patients with caudate HCC who have microscopic portal venous involvement may require adjuvant therapy as early recurrence is likely.

Segment-oriented approach to liver resection

Segment-oriented liver resection is a distinct surgical approach and represents the virtuosity of hepatic surgery. It is unique in the finesse of its execution and in its oncologic efficacy and safety. The varied combinations of segmentectomy allow greater flexibility and opportunity for liver surgeons to extirpate the equally diverse nature and location of intrahepatic pathologic conditions. The technique promotes tumor clearance while con-serving uninvolved parenchyma.

Limited hepatic resection for hepatocellular carcinoma in the caudate lobe

The most appropriate approach to treating hepatocellular carcinoma (HCC) in the caudate lobe has not yet been determined. A series of 197 patients who had undergone curative hepatic resection for HCC were analyzed. Fifteen patients had HCC in the caudate lobe: three in the Spiegel lobe (SP), three in the caudate process (CP), and nine in the paracaval portion (PC). Patients with HCCs in the SP and CP underwent partial hepatectomy. HCCs in the PC were approached in one of three ways: anterior approach and partial hepatectomy of the PC (Ant+PHx-PC), partial hepatectomy, or left lobectomy. Clinicopathologic variables, including the underlying liver disease, the mean tumor size, and the pathologic characteristics of HCC, did not differ between surgery of the caudate lobe and that of other segments. The overall survival was 88.9% at 3 years and 66.7% at 5 years after resection of HCC in the caudate lobe; the corresponding figures were 86.1% at 3 years and 68.6% at 5 years for the other segments. The recurrence-free survival rate was 51.9% at 3 years and 34.6% at 5 years for the caudate lobe, and it was 52.1% at 3 years and 32.8% at 5 years for the other segments. Clinicopathologic characteristics of HCCs originating in the caudate lobe were not different from those in the other segments. Limited resection of HCC in the caudate lobe confers a similar prognostic value as in other segments.

The surgical approach to HCC: our progress and results in Japan

Due to the prevalence of hepatitis virus infection, the incidence of hepatocellular carcinoma (HCC) is very high in Japan. Many techniques have been devised by Japanese surgeons to reduce the mortality rate after hepatectomy for HCC: preoperative precise evaluation of hepatic functional reserve, portal venous embolization as preoperative preparation, anatomical and nonanatomical limited resections using intraoperative ultrasonography, and intermittent inflow occlusion during liver transection. Several challenging surgical procedures are also being tried for advanced HCC: HCC with portal and hepatic venous tumor thrombus, multiple and/or recurrent HCC, and HCC in the caudate lobe. As a result, the latest national survey of HCC revealed that operative mortality was 0.9% and the 5-year survival rate after surgery was 52%. Living-donor liver transplantation for adult patients with HCC is another surgical treatment developed in Japan. After the success of adult-to-adult living donor liver transplant using a left liver graft in 1993, a right liver graft, a left liver graft with caudate lobe, and a right lateral sector graft were developed. Indications for reconstructing the middle hepatic vein tributaries in right liver grafts were also proposed. Consequently, in our series of 36 patients with HCC who underwent living-donor liver transplantation, operative mortality was 3%, and the 2-year survival rate was 84%.

Selective hepatic vascular exclusion versus Pringle maneuver in major liver resections: prospective study

Selective hepatic vascular exclusion (SHVE) and the Pringle maneuver are two methods used to control bleeding during hepatectomy. They are compared in a prospective randomized study, where 110 patients undergoing major liver resection were randomly allocated to the SHVE group or the Pringle group. Data regarding the intraoperative and postoperative courses of the patients are analyzed. Intraoperative blood loss and transfusion requirements were significantly decreased in the SHVE group, and postoperative liver function was better in that group. Although there was no difference between the two groups regarding the postoperative complications rate, patients offered the Pringle maneuver had a significantly longer hospital stay. The application of SHVE did not prolong the warm ischemia time or the total operating time. It is evident from the present study that SHVE performed by experienced surgeons is as safe as the Pringle maneuver and is well tolerated by the patients. It is much more effective than the Pringle maneuver for controlling intraoperative bleeding, and it is associated with better postoperative liver function and shorter hospital stay.

Different approaches to caudate lobectomy with “curettage and aspiration” technique using a special instrument PMOD: A Report of 76 cases

AIM: To study different approaches to caudate lobectomy with “curettage and aspiration” technique using Peng’s multifunctional operative dissector (PMOD). The surgical procedure of isolated complete caudate lobectomy was specially discussed.

METHODS: In 76 cases of various types of caudate lobectomy, three approaches were used including left side approach, right side approach, and anterior approach. Among the 76 cases, isolated complete caudate lobectomy was carried out in 6 cases with transhepatic anterior approach. The surgical procedure consisted of mobilization of the total liver, ligation and separation of the short hepatic veins, splitting the liver parenchyma through the Cantlie’s plane, ligation and division of the caudate portal triads from the hilum, dissection of the root of major hepatic veins, detachment of the caudate lobe from liver parenchyma.

RESULTS: The mean operative time was 285 ± 51 min, the mean blood loss was 1600 mL. No severe complications were observed. Among the 6 cases receiving isolated complete caudate lobectomy with transhepatic anterior approach, one case died 17 months after operation due to disease recurrence and liver failure, the other 5 cases have been alive without recurrence, with one longest survival of 49 months.

CONCLUSION: The choice of approach is essential to the success of caudate lobectomy. As PMOD and “curettage and aspiration” technique can delineate intrahepatic or extrahepatic vessels clearly, caudate lobe resection has become safer, easier and faster.

The caudate lobe of the liver: implications of embryology and anatomy for surgery

The anatomy of the caudate lobe has technical and possibly oncologic implications for surgeons. The complex anatomy of the lobe is clarified by embryologic and anatomic analysis. This posterior sector is embryonically and anatomically independent of the right and left liver and the main portal fissure. The caudate lobe represents the only part of the liver that is in contact with the vena cava, except at the entrance of the main hepatic veins into the vena cava, and provides an anastomosis between the hepatic veins and vena cava. The entire caudate lobe is a single anatomic segment that is defined by the presence of portal venous and hepatic arterial branches, which supply the lobe, draining biliary ducts, and hepatic veins. Because no separate veins, arteries, or ducts can be defined for the right paracaval portion of the posterior liver and because pedicles cross the proposed division between the right and left caudate, the concept of segment IX is abandoned. The significance of caudate anatomy is reflected in the increase in the frequency and safety of major hepatic resection for primary and metastatic tumors in the liver. Right hepatic lobectomy routinely involves resection of the right portion of the caudate lobe (C. Couinaud, unpublished data, 1999). In the case of hilar bile duct cancer, which may extend into the dorsal ducts (especially the right lateral duct), partial or total caudate lobectomy is often necessary for complete extirpation of the tumor. Isolated caudate lobectomy can be performed for hepatocellular carcinoma that arises in the caudate lobe or for other tumors that arise in the lobe. The caudate lobe can be resected as part of the donor liver in preparation for a living related donor transplantation. Knowledge of the surgical anatomy of the caudate lobe is an essential part of the repertoire for surgeons who perform liver transplants or treat hepatobiliary cancer.

Surgical outcomes of isolated caudate lobe resection: a single series of 19 patients

BACKGROUND

Isolated caudate lobe resection is a complex surgical procedure that requires technical expertise and knowledge of the surgical anatomy.

METHODS

All consecutive patients who were operated on for isolated caudate lobe resections by the senior author were studied. En bloc resections with adjacent hepatic parenchyma (as part of extended hepatectomies) or partial resections of the caudate lobe were excluded. Follow-up was completed by outpatient evaluation and mail correspondence.

RESULTS

Nineteen patients met the inclusion criteria (6 male, 13 female). Mean age (+/-SD) was 52 (+/-3) years. Primary diagnoses were colorectal metastases, hemangioma, hepatocellular carcinoma, adenoma, and neuroendocrine metastases. Margins were negative in all but 1 patient. One patient needed inferior vena cava resection. Pringle's maneuver was used in 1 patient (5%). Mean (+/-SD) operative time was 211 (+/-15) minutes, and estimated blood loss was 760 (+/-150) mL. Median blood transfusion was 0 U (range, 0-4). Complications (bile leak) were seen in 1 patient (5%). Median length of stay was 7 days (range, 4-14). There were no perioperative deaths.

CONCLUSIONS

Isolated caudate lobe resection is a feasible procedure that can be done with low morbidity/mortality. Sound surgical judgment and detailed knowledge of the caudate lobe anatomy are keys for a safe performance of this procedure.

Liver resection with repair of major hepatic veins

BACKGROUND

Liver resections for tumors adjacent to major hepatic veins often require reconstruction of venous wall defects. We describe a new operative approach that facilitates repair of major hepatic veins during hepatectomies.

METHODS

In 3 cases of liver tumors, the resection line had to include partially the wall of the right hepatic vein, middle hepatic vein and left hepatic vein of the preserved liver. The procedure was carried out by employing portal triad clamping combined with extrahepatic occlusion of the hepatic veins. Venous grafts for vascular repair were harvested from the inferior mesenteric vein.

RESULTS

In all 3 patients, histology showed tumor-free resection margins. Follow-up of 32 to 42 months revealed no recurrence and excellent liver function.

CONCLUSIONS

Combination of selective hepatic vascular exclusion with venous repair techniques, facilitates extensive liver resections in patients with tumors adjacent to the major hepatic veins and maximizes preservation of healthy liver tissue.