Hepatic resection with reconstruction of the inferior vena cava or hepatic venous confluence for metastatic liver tumor from colorectal cancer

Resection of Colorectal Liver Metastases with Major Vessel Involvement

BACKGROUND

Treatment of CRLM with major vessel involvement is still challenging and valid data on outcomes are still rare. We analyzed our experience of hepatectomies with resection and reconstruction of major hepatic vessels with regard to operative and perioperative details, histopathological findings and oncological outcome.

METHODS

Data of 32 hepatectomies with major hepatic vessel resections and reconstructions were included. Results were correlated with perioperative and oncological outcome.

RESULTS

Out of 1236 surgical resections due to CRLM, we performed 35 major hepatic vessel resections and reconstructions in 32 cases (2.6%) during the study period from January 2008 to March 2023. The vena cava inferior (VCI) was resected and reconstructed in 19, the portal vein (PV) in 6 and a hepatic vein (HV) in 10 cases. Histopathological examination confirmed a vascular infiltration in 6/32 patients (VCI 3/17, HV 2/10 and PV 1/6). There were 27 R0 and 5 R1 resections. All R1 situations affected the parenchymal margin. Vascular wall margins were R0. Ninety-day mortality was 0. The median overall survival (OS) for the patient group with vascular infiltration (V1) was 21 months and for the V0 group 33.3 months.

CONCLUSION

Liver resections with vascular resection and reconstruction are rare and histological vessel infiltration occurs seldom. In cases with presumed vascular wall infiltration, liver resection combined with major vessel resection and reconstruction can be performed with low morbidity and mortality. We prefer a parenchymal sparing liver resection with vascular resection and reconstruction to achieve negative resection margins, but in technically difficult cases with higher risk for postoperative complications, tumor detachment from vessels without resection is a most reasonable surgical alternative.

[Vascular reconstruction and transplantation technologies in liver surgery (part II)]

OBJECTIVE

To systematize tactical and technical aspects of liver resections with reconstruction of afferent and efferent blood supply and/or inferior vena cava; to study postoperative outcomes in patients with focal liver lesions using transplantation technologies.

MATERIAL AND METHODS

We enrolled 413 patients with parasitic lesions, primary and secondary liver tumors involving great vessels (portal vein, hepatic artery, hepatic veins, inferior vena cava, right atrium). All ones underwent liver resections with vascular resection and reconstruction, as well as liver autotransplantation in vivo, ante situ (ex situ in vivo), extracorporeal liver resections with autotransplantation (ex vivo).

RESULTS

We obtained satisfactory immediate results after liver resections using transplantation technologies.

CONCLUSION

Transplantation technologies in liver surgery can significantly increase resectability of tumors and survival of patients. Transplantation technologies are an important new surgical strategy and necessary option in modern hepatic surgery.

Surgery of Colorectal Liver Metastases Involving the Inferior Vena Cava: A Systematic Review

Combined hepatic and inferior vena cava (IVC) resection is the only potentially curative treatment for patients with colorectal liver metastases (CRLM) involving the IVC. Most of the existing data come from case reports or small case series. In this paper, a systematic review based on the PICO strategy was performed in accordance with the PRISMA statement. Papers from January 1980 to December 2022 were searched in Embase, PubMed, and the Cochrane Library databases. Articles considered for inclusion had to present data on simultaneous liver and IVC resection for CRLM and report surgical and/or oncological outcomes. From a total of 1175 articles retrieved, 29, including a total of 188 patients, met the inclusion criteria. The mean age was 58.3 ± 10.8 years. The most frequent techniques used were right hepatectomy ± caudate lobe for hepatic resections (37.8%), lateral clamping (44.8%) for vascular control, and primary closure (56.8%) for IVC repair. The thirty-day mortality reached 4.6%. Tumour relapse was reported in 65.8% of the cases. The median overall survival (OS) was 34 months (with a confidence interval of 30-40 months), and the 1-year, 3-year, and 5-year OS were 71.4%, 19.8%, and 7.1%, respectively. In the absence of prospective randomized studies, which are difficult to perform, IVC resection seems to be safe and feasible.

The impact of multivisceral liver resection on short- and long-term outcomes of patients with colorectal liver metastasis: A systematic review and meta-analysis

The impact of Multivisceral Liver Resection (MLR) on the outcome of patients with Colorectal Liver Metastasis (CRLM) is unclear. The present systematic review aimed to compare patients with CRLM who underwent MLR versus standard hepatectomy regarding short- and long-term outcomes. MLR is a feasible procedure but has a higher risk of major complications. MLR did not negatively affect long-term survival, suggesting that an extended resection is an option for potentially curative treatment for selected patients with CRLM.

Parenchymal-sparing hepatectomy with hepatic vein resection and reconstruction

BACKGROUND

Hepatectomy remains the most important treatment modality for most malignant liver tumors. Vascular involvement stays a reason for unresectability or major parenchymal resection. A possible way to avoid this is parenchymal-sparing hepatectomy (PSHX) with vascular resection and reconstruction (HVRR). In this article, we aim to demonstrate the specific role of this technique in avoiding post-hepatectomy liver failure (PHLF).

METHODS

A retrospective analysis of 10 patients who underwent HVRR was conducted. ^99mTechnetium-mebrofenin hepatobiliary scintigraphy (HBS) was used to predict the future liver remnant function (FLRF). Calculations were made for each patient to compare HVRR and major hepatectomy (with or without portal vein embolization).

RESULTS

In our cohort, there was no perioperative mortality. Two patients suffered a Clavien-Dindo grade 3a complication and none had clinically significant PHLF. Estimated FLRF was significantly higher in HVRR compared to major hepatectomy after portal vein embolization (p < .005).

CONCLUSIONS

Instead of focusing on inducing liver remnant hypertrophy, preserving parenchyma through HVRR can be an interesting treatment strategy. It can be performed with an acceptable operative risk. Calculations of FLRF (using HBS) suggest that this approach is able to reduce the risk for PHLF and related morbidity or mortality.

Case series of extended liver resection associated with inferior vena cava reconstruction using peritoneal patch

INTRODUCTION

Among various reported techniques for inferior vena cava (IVC) reconstruction, the superiority of one technique over another has not been clearly established. This study aimed at reporting the technical aspects of caval reconstruction using peritoneal patch during extended liver resections.

METHODS

All consecutive patients who underwent extended liver resection associated with anterolateral caval reconstruction using a peritoneal patch from 2016 to 2019 were included in this study. Technical insights, intra-operative details, short and long-term results were reported.

RESULTS

Overall six patients underwent caval reconstruction using peritoneal patch under total vascular exclusion. Half of them required veno-venous bypass. Caval involvement ranged from 30 to 50% of the circumference and from 5 to 7 cm of the length of the IVC. Caval reconstructions was performed using a peritoneal patch harvested from the falciform ligament in four cases and from the right pre-renal peritoneum and right part of the diaphragm in one Case each. Three cases underwent associated reimplantation the remnant hepatic vein. Median intra-operative blood loss and TVE duration were 500 ml and 41 min, respectively. One case experienced a severe complication (liver failure leading to death). R₀ resection was achieved in all patients. All patients had patent IVC and remnant hepatic vein at last follow-up and none was on long-term therapeutic anticoagulation.

CONCLUSION

Caval reconstruction using a peritoneal patch in patients undergoing extended liver resection is feasible and cost-effective and associated with excellent long-term results.

Inferior vena cava resection and reconstruction with a peritoneal patch for a leiomyosarcoma: A case report

•

Leiomyosarcoma of the inferior vena cava are very rare neoplasm with a limited responsiveness to medical therapy.

•

Surgery seems to be the only chance of cure.

•

Complex vascular resection are often necessary and required accurate reconstruction technique.

•

Peritoneal patch is an efficient and safe option to repair venous defects and it is gaining great attention in recent years.

Introduction

Leiomyosarcomas (LMs) of the inferior vena cava (IVC) are very rare neoplasms seldom reported in the literature. The majority of patients does not present with specific abdominal pain and IVC LMs are used to become symptomatic with the increase of tumor volume. The role of chemotherapy or radiotherapy is not yet defined and surgical resection seems to be the only chance to improve survival rates.

Presentation of case

We present a case of a 58-year-old female with a recent diagnosis of IVC LM who underwent surgery with a partial resection of the anterior wall of the vein using a lateral and partial vein clamping. The primary repair of the defect could result in stricture of the vein, so a parietal peritoneum patch was used for the vein reconstruction. The postoperative course was uneventful.

Discussion

Actual evidence suggests that vascular sarcomas have limited responsiveness to cytotoxic chemotherapy and chemoradiotherapy, so surgery is the treatment of choice. Major surgery entailing multivisceral and complex vascular resection is usually necessary to achieve negative margins and accurate vascular reconstruction techniques are mandatory to avoid serious circulatory complications. Different kinds of graft (biological or synthetics) are available for the reconstruction, with intrinsic advantages and limitations. The use of peritoneal patches seems a valid and cheap option for vascular reconstruction and it is gaining great attention in recent years.

Conclusion

This case demonstrates that peritoneal graft could be a safe option to manage IVC defects in expert hands. A brief review of literature is also included.

Autologous peritoneal graft for venous vascular reconstruction after tumor resection in abdominal surgery: a systematic review

Radical surgical resection (R0) is the only option to cure patients with borderline resectable or multivisceral intraabdominal malignancies involving major vessels. Autologous peritoneal flap has been described as a safe and versatile option for vascular reconstruction, but still limited experience exists regarding its use. An extensive literature review was performed to analyze results of vascular reconstruction with an autologous peritoneal graft. Fifteen reports were found for a total of 94 patients. No cases of arterial vascular reconstruction were found. Two different types of peritoneal patch have been described, backed (APFG, 30 patients) or not backed (ANFP, 64 patients) by posterior rectus sheath. A patch type of reconstruction was adopted in 70 patients (74.5%), while a tubular reconstruction in 24 (25.5%). Postoperative mortality was 5.3% (5 cases). Graft outcomes with very heterogeneous follow-ups (7 days-47 months) were available only in 85 patients (90.4%). Among them, a graft patency was documented in 80 patients (94.1%), while a stenotic graft was reported in 5 patients (5.9%). No differences in graft outcomes were observed between the patch and tubular groups (p = 0.103), nor between the ANFP and APFG groups (p = 0.625). In reported experiences, autologous peritoneal graft seems to represent a safe and versatile option for functional restoration of venous vascular anatomy after resection, especially in operations with high risk of contamination, trauma, liver transplantation and unplanned vascular resection. Unfortunately, the data available in the literature do not make it possible to draw any evidence-based conclusions on these considerations.

How to increase the resectability of initially unresectable colorectal liver metastases: A surgical perspective

Although surgical resection is the only treatment of choice that can offer prolonged survival and a chance of cure in patients with colorectal liver metastases (CRLM), nearly 80% of patients are deemed to be unresectable at the time of diagnosis. Considerable efforts have been made to overcome this initial unresectability, including expanding the indication of surgery, the advent of conversion chemotherapy, and development and modification of specific surgical techniques, regulated under multidisciplinary approaches. In terms of specific surgical techniques, portal vein ligation/embolization can increase the volume of future liver remnant and thereby reduce the risk of hepatic insufficiency and death after major hepatectomy. For multiple bilobar CRLM that were traditionally considered unresectable even with preoperative chemotherapy and portal vein embolization, two-stage hepatectomy was introduced and has been adopted worldwide with acceptable short- and long-term outcomes. Recently, ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) was reported as a novel variant of two-stage hepatectomy. Although issues regarding safety remain unresolved, rapid future liver remnant hypertrophy and subsequent shorter intervals between the two stages lead to a higher feasibility rate, reaching 98%. In addition, adding radiofrequency ablation and vascular resection and reconstruction techniques can allow expansion of the pool of patients with CRLM who are candidates for liver resection and thus a cure. In this review, we discuss specific techniques that may expand the criteria for resectability in patients with initially unresectable CRLM.

New two-step wedge liver resection technique: "zoom resection": A case report

Different surgical procedures have been described for the treatment of colorectal liver metastases. The appropriate surgical approach depends, among many other factors, on the relationship between liver metastases and suprahepatic veins. If possible, the detachment of colorectal liver metastasis from suprahepatic veins is a good alternative liver parenchyma sparing technique. In this study, we describe a new two-step wedge liver resection technique for colorectal liver metastases located between suprahepatic veins. Prior to resection, intraoperative ultrasound is employed in order to plan and guide both steps. Initially, we place stitches and resect a cylindrical piece of normal liver parenchyma above the tumor and suprahepatic veins. Next, we place stitches on the future specimen located between suprahepatic veins, then resect it. The main advantages of this procedure are the good visualization and vascular control that may be achieved during the detachment of the tumor from suprahepatic veins. We call this procedure "zoom resection" because its dynamics are similar to the workings of a photograph camera's telescopic system. We present the case of a 55-year-old patient diagnosed with multiple colorectal liver metastases, one of which was resected through this technique.

Surgical outcome of extended liver resections for colorectal liver metastasis compared with standard liver resections

Colorectal liver metastatic lesions sometimes invade adjacent organs. A hepatectomy is often extended to include the involved adjacent organ to achieve negative surgical margins. The purpose of the present retrospective study was to evaluate the surgical outcomes of extended liver resections and patients' prognoses. The medical records of 178 patients with colorectal liver metastasis who underwent liver resections in the Department of Gastroenterological Surgery at Osaka University Hospital (Suita, Japan), from 2000 to 2015 were reviewed. These patients were divided into two groups: the extended resection group (n=20) and the non-extended resection group (n=158). The disease-free and overall survival curves were estimated with the Kaplan-Meier method and analyzed with the log rank test. It was observed that the extended resection group had longer operation times and increased blood loss, however perioperative morbidity was similar. The organs resected most frequently were the diaphragm (n=10) and inferior vena cava (n=5). Overall survival rates in the extended resection group were lower compared with the non-extended resection group (5-year survival rates; 45.0 vs. 67.9%), however the difference was not significant. It was indicated that the aggressive hepatectomy combined with resection of adjacent organs was an acceptable treatment with low perioperative morbidity. The overall survival rate may not be inferior to that of simple hepatectomy.

Modified ante situm liver resection without use of cold perfusion nor veno-venous bypass for treatment of hepatic lesions infiltrating the hepatocaval confluence

PURPOSE

Treatment of malignancies invading the hepatic veins/inferior vena cava is a surgical challenge. An ante situm technique allows luxation of the liver in front of the situs to perform tumor resection. Usually, cold perfusion and veno-venous bypass are applied. Our experience with modified ante situm resection relying only on total vascular occlusion is reported.

METHODS

Retrospective analysis on an almost 15-year experience with ante situm resection without application of cold perfusion or veno-venous bypass RESULTS: The ante situm technique was applied on eight patients. Five individuals were treated due to intrahepatic cholangiocellular cancer and one case each for mixed cholangio-/hepatocellular carcinoma, colorectal liver metastasis, and pheochromocytoma. Trisectorectomy (n = 4), left hemihepatectomy, right hepatectomy, atypical resection, or mesohepatectomy (each n = 1) were performed, combined with dissection of suprahepatic/retrohepatic vena cava/hepatic veins. Venous reconstruction was achieved by reimplantation of hepatic veins with/without vascular replacement using allogeneic donor veins or PTFE grafts. Median total vascular occlusion of the liver was 23 min. Severe morbidity occurred in three patients (Dindo-Clavien > 3A). R0 status was achieved in six cases with a median overall survival of 33.5 months.

CONCLUSIONS

Ante situm liver resection can be applied without cold perfusion nor veno-venous bypass with acceptable morbidity and mortality. However, this procedure remains challenging even for the experienced hepato-pancreato-biliary surgeon.

A pooled analysis of combined liver and inferior vena cava resection for hepatic malignancy

BACKGROUND

Limited data are currently available to address the safety and efficacy of combined resection of the liver and inferior vena cava (IVC) for hepatic malignancies.

METHODS

A systematic review was performed to identify relevant studies. Pooled individual data were examined for the clinical outcome of combined resection of the liver and IVC for hepatic malignancies.

RESULTS

A total of 258 patients were described in 38 articles eligible for inclusion. Resections were performed for colorectal liver metastasis (CLM) [n = 128 (50%)], intrahepatic cholangiocarcinoma (ICC) [n = 51 (20%)], hepatocellular carcinoma (HCC) [n = 48 (19%)], and other pathologies [n = 31 (11%)]. There were 14 (5%) perioperative deaths. The median survival duration was 34 months, and the 1-, 3- and 5-year overall survival (OS) rate was 79%, 46% and 33%, respectively. The 5-year OS rate was 26% for CLM, 37% for ICC, and 30% for HCC.

CONCLUSION

Combined resection of the liver and IVC for hepatic malignancies is safe and applicable, and offers acceptable survival outcomes.

Safety and efficacy of venous reconstruction in liver resection using cryopreserved homologous veins

BACKGROUND

Only a few studies have reported the resection and reconstruction of major hepatic veins during hepatectomy. Here, we present our strategy and techniques for venous reconstruction with cryopreserved homologous veins, and describe the surgical outcome.

METHODS

Among 2,387 hepatectomy patients, 39 patients who required hepatic venous reconstruction were reviewed retrospectively. Venous reconstruction was performed to secure a non-congested liver remnant volume of at least 40% of the total liver volume.

RESULTS

There was no operative mortality, and the severe morbidity rate was 5% in this series. A total of 41 veins were reconstructed; 30 with homologous veins (73.2%) and 11 with autologous veins (26.8%), with the middle hepatic vein being the most frequent (n = 23, 56%). Interposition grafting was performed more often (P = 0.003), the length of the venous resection was longer (P = 0.007), and pathologic wall infiltration of the vein was revealed more often (P = 0.002) in the homologous graft group than in the autologous graft group. The 1-, 2-, and 3-year overall patency of the reconstructed veins was 55.4%, 46.3%, and 46.3%, respectively.

CONCLUSIONS

Aggressive venous reconstruction during hepatectomy using cryopreserved homologous veins is a feasible option with satisfactory short-term outcomes, and may be warranted to improve operative safety.

Liver transection using indocyanine green fluorescence imaging and hepatic vein clamping

BACKGROUND

Three-dimensional (3D) imaging has facilitated liver resection with excision of hepatic veins by estimating the liver volume of portal and hepatic venous territories. However, 3D imaging cannot be used for real-time navigation to determine the liver transection line. This study assessed the value of indocyanine green (ICG) fluorescence imaging with hepatic vein clamping for navigation during liver transection.

METHODS

Consecutive patients who underwent liver resection with excision of major hepatic veins between 2012 and 2013 were evaluated using ICG fluorescence imaging after clamping veins and injecting ICG. Regional fluorescence intensity (FI) values of non-veno-occlusive regions (FI_Non ), veno-occlusive regions (FI_VO ) and ischaemic regions (FI_IS ) were calculated using luminance analysing software.

RESULTS

Of the 21 patients, ten, four and seven underwent limited resection, monosegmentectomy/sectionectomy and hemihepatectomy respectively, with excision of major hepatic veins. Median veno-occlusive liver volume was 80 (range 30-458) ml. Fluorescence imaging visualized veno-occlusive regions as territories with lower FI compared with non-veno-occlusive regions, and ischaemic regions as territories with no fluorescence after intravenous ICG injection. Median FI_IS /FI_Non was lower than median FI_VO /FI_Non (0·22 versus 0·59; P = 0·002). There were no deaths in hospital or within 30 days, and only one major complication.

CONCLUSION

ICG fluorescence imaging with hepatic vein clamping visualized non-veno-occlusive, veno-occlusive and ischaemic regions. This technique may guide liver transection by intraoperative navigation, enhancing the safety and accuracy of liver resection.

Parenchyma-Sparing Hepatectomy with Vascular Reconstruction Techniques for Resection of Colorectal Liver Metastases with Major Vascular Invasion

Background

Resectability of colorectal liver metastasis (CRLM) depends on major vascular involvement and is affected by chemotherapy-induced liver injury. Parenchyma-sparing with combined resection and reconstruction of involved vessels may expand the indications and safety of hepatectomy.

Methods

Of 92 patients who underwent hepatectomy for CRLM, 15 underwent major vascular resection and reconstruction. The reconstructed vessels were the portal vein (PV) in five cases, the major hepatic vein (HV) in nine cases, and the inferior vena cava in six cases.

Results

All PV reconstructions were direct anastomoses. The HV was reconstructed with an autologous inferior mesenteric venous patch or an external iliac vein interposition graft. Total hepatic vascular exclusion was performed for six patients. Of nine patients with HV reconstruction, three had tumors involving all three major HVs, in whom the left HV was reconstructed as an only vein after extended right hepatectomy. In another six patients, multiple bilobar tumors or tumors in the liver that had chemotherapy-induced injury involved one or two HVs. Parenchyma-sparing by reconstruction of the HV was performed to secure the residual liver function. The patients with vascular reconstruction had an operative time of 462 ± 111 min and a blood loss of 1278 ± 528 mL. No complication classified as Clavien–Dindo 3 or more developed. The median hospital stay was 17 days (range 8–26 days). The cumulative 5-year survival rate for all the patients was 54.6 %, with no significant difference according to vascular reconstruction.

Conclusion

Parenchyma-sparing hepatectomy combined with vascular reconstruction is a useful option to avoid major hepatectomy among various procedures for resection of CRLM with major vascular invasion.

Extreme liver surgery as treatment of liver tumors involving the hepatocaval confluence

OBJECTIVE

Analyze the characteristics, surgical technique, morbidity and survival of patients treated with extreme liver surgery.

MATERIALS AND METHODS

We present a series of consecutive patients with malignant liver tumors in hepatocaval confluence treated in a single center with extreme liver surgery (April 2008-March 2015). Data were collected prospectively and analyzed with SPSS 21.0.

RESULTS

12 patients were included. 50 % were male and 50 % were female with a mean age of 59 ± 10 years old. The median of comorbidities was 7 according to the Charlson Age Comorbidity Index. The 75 % of the tumors were metastases, most of them from colorectal cancer. Most of the patients received neoadjuvant chemotherapy and in 58 % preoperative portal embolization was performed. Major hepatectomies were performed (66.7 % extended right hepatectomy, 33.3 % left extended hepatectomy). The 83.3 % of the patients needed vascular reconstruction. Postoperative morbidity was more than grade II in 50 % of the patients according to Dindo-Clavien classification. There was no intraoperative mortality. The postoperative mortality rate at 90 days was 33 % due to hepatic failure and biliary fistula. In December 2015, 33 % of the patients are still alive with a mean survival of 19 months (13-23) with an ECOG Performance Status of 0.

CONCLUSION

Extreme liver surgery carries a high rate of morbidity and mortality that seem to increase with age and with higher tumor volumes, according to the literature. It is a therapeutic option to consider in patients with low comorbidity suffering from malignant neoplasms that involve the hepatocaval confluence, when no other treatment with curative intention can be performed.

Parietal Peritoneum as an Autologous Substitute for Venous Reconstruction in Hepatopancreatobiliary Surgery

OBJECTIVE

To evaluate the parietal peritoneum (PP) as an autologous substitute for venous reconstruction during hepatopancreatobiliary (HPB) surgery.

BACKGROUND

Venous resection during liver or pancreatic resection may require a rapidly available substitute especially when the need for venous resection is unforeseen.

METHODS

The PP was used as an autologous substitute during complex liver and pancreatic resections. Postoperative anticoagulation was standard and venous patency was assessed by routine computed tomographic scans.

RESULTS

Thirty patients underwent vascular resection during pancreatic (n = 18) or liver (n = 12) resection, mainly for malignant tumors (n = 29). Venous resection was an emergency procedure in 4 patients due to prolonged vascular occlusion. The PP, with a mean length of 22 mm (15-70), was quickly harvested and used as a lateral (n = 28) or a tubular (n = 2) substitute for reconstruction of the mesentericoportal vein (n = 24), vena cava (n = 3), or hepatic vein (n = 3). Severe morbidity included Clavien grade-III complications in 4 (13%) patients but there was no PP-related or hemorrhagic complications. Histological vascular invasion was present in 18 (62%) patients, and all had an R0 resection (100%). After a mean follow-up of 14 (7-33) months, all venous reconstructions were patent except for 1 tubular graft (97%).

CONCLUSIONS

A PP can be safely used as a lateral patch for venous reconstruction during HPB surgery; this could help reduce reluctance to perform vascular resection when oncologically required. Clinical trials identification: NCT02121886.

Repeated hepatic resection combined with inferior vena cava replacement: Case report and review of literature

INTRODUCTION

Advanced tumors of the liver involving the inferior vena cava (IVC) have always been considered a contraindication to surgery.

PRESENTATION OF CASE

We report a case of a patient, who previously underwent right hepatectomy, with recurrence of colorectal liver metastasis invading the IVC. The patient had a liver resection together with replacement of the vena cava using a ringed polytetrafluoroethylene (PTFE) graft tube. The operation was carried out in hepatic vascular exclusion (HVE) without the use of veno-venous bypass. The patient was healthy and tumor-free at 6 months post-surgery.

DISCUSSION

In patients with hepatic malignancy involving the IVC, extended hepatic resection and reconstruction of the IVC is often the prerequisite to obtaining a resection margin.

CONCLUSION

Extended hepatic resection with IVC reconstruction for hepatic malignancy may offer a chance of cure to selected patients who otherwise have poor survival rates.

Role of surgery in colorectal cancer liver metastases

Colorectal carcinoma (CRC) is the third most common cancer, and approximately 35%-55% of patients with CRC will develop hepatic metastases during the course of their disease. Surgical resection represents the only chance of long-term survival. The goal of surgery should be to resect all metastases with negative histological margins while preserving sufficient functional hepatic parenchyma. Although resection remains the only chance of long-term survival, management strategies should be tailored for each case. For patients with extensive metastatic disease who would otherwise be unresectable, the combination of advances in medical therapy, such as systemic chemotherapy (CTX), and the improvement in surgical techniques for metastatic disease, have enhanced prognosis with prolongation of the median survival rate and cure. The use of portal vein embolization and preoperative CTX may also increase the number of patients suitable for surgical treatment. Despite current treatment options, many patients still experience a recurrence after hepatic resection. More active systemic CTX agents are being used increasingly as adjuvant therapy either before or after surgery. Local tumor ablative therapies, such as microwave coagulation therapy and radiofrequency ablation therapy, should be considered as an adjunct to hepatic resection, in which resection cannot deal with all of the tumor lesions. Formulation of an individualized plan, which combines surgery with systemic CTX, is a necessary task of the multidisciplinary team. The aim of this paper is to discuss different approaches for patients that are treated due to CRC liver metastasis.

Hepatic colorectal metastases involving infra-hepatic inferior vena cava in high risk patients for extended resection: an alternative method for achieving radical resection in patient with borderline liver remnant

Resection is the only chance of cure for isolated liver metastases from colorectal cancer. In the case of extended parenchymal resections, one crucial point is the ischemic damage to the remnant liver. We report an alternative technique for extremely extended liver resections without total hilar clamping for borderline liver remnants. Two patients presented with invasion of the infrahepatic vena cava, both with an estimated live remnant ≤20 %. The crucial point of the technique is the absence of a portal triad clamping in under beating heart-extracorporeal circulation. In both patients resection margins were free of disease. No signs of liver insufficiency were noted. Survival was more than 2 years in both cases. We believe that aggressive treatment of liver colorectal metastases should be given to all suitable patients. This operation may be added to the techniques that can be offered to these patients.

Limits of colorectal liver metastases resectability: how and why to overcome them? For progress in cancer research

Offering surgery is to date the best case scenario for patients with colorectal liver metastases (CRLM). Few oncological topics have progressed as much as the treatment of CRLM. New surgical techniques, conversion therapies, and imaging allow us to pursue the ultimate limit for surgery of CLM before compromising patient benefits. Pushing the limits of surgery involves pushing the limits of conversion therapies too, increasingly taking risks in the surgical process. Finally, toxicities add up and the patient benefit could disappear. The apparent paradox of efficiency and toxicity might be addressed by separating the two treatment targets: (1) The metastatic burden for which a clear escalation in medical and surgical aggressiveness is still required. (2) The healthy parenchyma which should be preserved as much as possible and for which a clear de-escalation is anticipated. A new strategy exists that integrates both fundamental endpoints in the battle against CLM.

Liver metastases in close contact to hepatic veins ablated under vascular exclusion

BACKGROUND

Liver metastases (LM) in close contact to hepatic veins (HV) are a frequent cause of unresectability. Reconstruction of hepatic veins is technically difficult and outcomes are poor. Intra-operative radiofrequency ablation (IRFA) with vascular exclusion (VE) may be a useful approach.

METHODS

Out of 358 patients operated for LM, 22 with LM close to a HV treated by IRFA under VE with at least one year of follow-up were included in this retrospective study. Technical success was evaluated at four months by CT scan of the ablated lesion. Complications; local, hepatic and extra-hepatic recurrence rates, and overall survival are reported.

RESULTS

The median number of metastases was 4.5 [range: 1-12]. Seventeen patients had bilateral metastases. The median size of ablated lesions was 2 cm [range: 1-5.5]. Seven complications occurred (1 Grade 1, 2 Grade 3b and 4 Grade IVa), with no mortality. No recurrence of ablated lesions was detected at four months or during follow-up. Seventeen patients had new or extra-hepatic lesions. Median overall survival for colorectal patients was 40 months 95%CI[17.5-not reached].

CONCLUSIONS

IRFA plus VE for LM in close contact to a HV is a novel approach, appearing to be a safe and effective technique which can extend the applications of liver metastases surgery.

Virtual liver resection: computer-assisted operation planning using a three-dimensional liver representation

In liver surgery, understanding the complicated liver structures and a detailed evaluation of the functional liver remnant volume are essential to perform safe surgical procedures. Recent advances in imaging technology have enabled operation planning using three-dimensional (3D) image-processing software. Virtual liver resection systems provide (1) 3D imaging of liver structures, (2) detailed volumetric analyses based on portal perfusion, and (3) quantitative estimates of the venous drainage area, enabling the investigation of uncharted fields that cannot be examined using a conventional two-dimensional modality. The next step in computer-assisted liver surgery is the application of a virtual hepatectomy to real-time operations. However, the need for a precise alignment between the preoperative imaging data and the intraoperative situation remains to be adequately addressed, since the liver is subject to deformation and respiratory movements during the surgical procedures. We expect that the practical application of a navigation system for transferring the preoperative planning to real-time operations could make liver surgery safer and more standardized in the near future.

Perioperative chemotherapy and liver resection for hepatic metastases of colorectal cancer

Surgical resection has played a major role in the treatment for colorectal liver metastases. The safety and efficacy of surgery for liver metastasis are obvious, although there are some differences between the western countries and Japan concerning the surgical indication, procedures, timing of chemotherapies in a perioperative period, and treatment of a primary disease. In future, long-term outcomes after surgical resection for colorectal liver metastases would be expected to be prolonged by combination of surgery and chemotherapies.

Systematic review and meta-analysis of follow-up after hepatectomy for colorectal liver metastases2

Background

The evidence surrounding optimal follow-up after liver resection for colorectal metastases remains unclear. A significant proportion of recurrences occur in the early postoperative period, and some groups advocate more intensive review at this time.

Methods

A systematic review of literature published between January 2003 and May 2010 was performed. Studies that described potentially curative primary resection of colorectal liver metastases that involved a defined follow-up protocol and long-term survival data were included. For meta-analysis, studies were grouped into intensive (more frequent review in the first 5 years after resection) and uniform (same throughout) follow-up.

Results

Thirty-five studies were identified that met the inclusion criteria, involving 7330 patients. Only five specifically addressed follow-up. Patients undergoing intensive early follow-up had a median survival of 39·8 (95 per cent confidence interval 34·3 to 45·3) months with a 5-year overall survival rate of 41·9 (34·4 to 49·4) per cent. Patients undergoing routine follow-up had a median survival of 40·2 (33·4 to 47·0) months, with a 5-year overall survival rate of 38·4 (32·6 to 44·3) months.

Conclusion

Evidence regarding follow-up after liver resection is poor. Meta-analysis failed to identify a survival advantage for intensive early follow-up.

Venous reconstruction based on virtual liver resection to avoid congestion in the liver remnant

BACKGROUND

Hepatic vein (HV) reconstruction may prevent venous congestion following resection of liver tumours that encroach on major HVs. This study aimed to identify criteria for venous reconstruction based on preoperative evaluation of venous congestion.

METHODS

A volumetric analysis using image-processing software was performed in selected patients with liver tumours suspected on preoperative imaging of major HV invasion. The size of the non-congested liver remnant (NCLR) was calculated by subtracting the congested area from the liver remnant. Venous reconstruction was scheduled in patients who met the following criteria: normal liver function (indocyanine green retention rate at 15 min (ICGR(15) ) of less than 10 per cent) with a NCLR smaller than 40 per cent of total liver volume (TLV), or liver dysfunction (ICGR(15) 10-20 per cent) with a NCLR smaller than 50 per cent of TLV. Surgical outcomes and liver regeneration were investigated.

RESULTS

A total of 55 patients with suspected HV invasion were enrolled. Sacrifice of one or more HVs was deemed possible in 37 patients. Venous reconstruction was scheduled in 18 patients. At operation, there was seen to be no venous involvement in 11 patients. The HV was sacrificed in 29 patients, and preserved or reconstructed in 24. Volume restoration ratios at 3 months were similar in the sacrifice (88 per cent) and preserve (87 per cent) groups. Operating time was shorter (465 min) and blood loss was lower (580 ml) in the sacrifice than in the preserve group (523 min and 815 ml respectively).

CONCLUSION

The HV can be sacrificed safely according to the proposed criteria, reducing surgical invasiveness without influencing the postoperative course.

Liver resection for advanced or aggressive colorectal cancer metastases in the era of effective chemotherapy: a review

Liver surgery has been known to cure metastatic colorectal cancer in a small proportion of patients. However, advances in procedural technique and chemotherapy now allow more patients to have safe, potentially curative surgery. Here we review surgery for unresectable colorectal liver metastases using an expert multidisciplinary approach. With multidisciplinary management of patients with effective chemotherapy that can downstage metastases, more patients with previously inoperable disease can benefit from surgery. Portal vein embolization results in hypertrophy of the future liver remnant; on occasions, combining embolization with staged liver resection permits potentially curative surgery for patients previously unable to survive resection. However, increasing use of chemotherapy has raised awareness of potential hepatotoxicity and other deleterious effects of cytotoxic agents. Prolonged prehepatectomy chemotherapy therefore can reduce resectability even using a 2-stage procedure. Suitable timing of surgery for unresectable liver metastases during chemotherapy is critical. Because of advances in chemotherapy, colorectal cancer, like ovarian cancer, can now show survival benefit from maximum surgical debulking. Benefit from such maximum hepatic debulking surgery for metastatic colorectal disease is uncertain, but likely. Surgery in isolation may be approaching technical limits, but is now likely to help more patients because of the success of complementary strategies, particularly newer chemotherapy and targeted therapy. Expert individualized multidisciplinary treatment planning and problem-solving is essential.

Safety and efficacy of hepatic vein reconstruction for colorectal liver metastases

BACKGROUND

Colorectal liver metastases with hepatic vein (HV) involvement may require combined resection of the liver and HV. However, the short- and long-term outcomes of such a procedure remain unclear.

METHODS

We reviewed 16 cases of liver resection with major HV resection and reconstruction.

RESULTS

The patients had a median age of 58.5 years (range, 50-74 y). In total, 18 HVs were reconstructed using a customized great saphenous vein graft (n = 10), direct anastomosis (n = 1), external iliac vein (n = 2), portal vein (n = 1), umbilical vein patch graft (n = 3), or ovarian vein patch graft (n = 1). There was no hospital mortality, and the morbidity rate was 50%. With a median follow-up period of 30 months (range, 4-89 mo), 3 patients died of tumor recurrence and 13 were alive with (n = 6) and without (n = 7) disease. Cumulative 1-, 3-, and 5-year survival rates were 93%, 76%, and 76%, respectively.

CONCLUSIONS

HV resection and reconstruction combined with liver resection can be performed safely with reasonable long-term results.

Aggressive liver resection including major-vessel resection for colorectal liver metastases

AIM

To clarify short- and long-term outcomes of combined resection of liver with major vessels in treating colorectal liver metastases.

METHODS

Clinicopathologic data were evaluated for 312 patients who underwent 371 liver resections for metastases from colorectal cancer. Twenty-five patients who underwent resection and reconstruction of retrohepatic vena cava, major hepatic veins, or hepatic venous confluence during hepatectomies were compared with other patients, who underwent conventional liver resections.

RESULTS

Morbidity was 20% (75/371) and mortality was 0.3% (1/312) in all patients after hepatectomy. Hepatic resection combined with major-vessel resection/reconstruction could be performed with acceptable morbidity (16%) and no mortality. By multivariate analysis, repeat liver resection (relative risk or RR, 5.690; P = 0.0008) was independently associated with resection/reconstruction of major vessels during hepatectomy, as were tumor size exceeding 30 mm (RR, 3.338; P = 0.0292) and prehepatectomy chemotherapy (RR, 3.485; P = 0.0083). When 312 patients who underwent a first liver resection for initial liver metastases were divided into those with conventional resection (n = 296) and those with combined resection of liver and major vessels (n = 16), overall survival and disease-free rates were significantly poorer in the combined resection group than in the conventional resection group (P = 0.02 and P < 0.01, respectively). A similar tendency concerning overall survival was observed for conventional resection (n = 37) vs major-vessel resection combined with liver resection (n = 7) performed as a second resection following liver recurrences (P = 0.09). Combined major-vessel resection at first hepatectomy (not performed; 0.512; P = 0.0394) and histologic major-vessel invasion at a second hepatectomy (negative; 0.057; P = 0.0005) were identified as independent factors affecting survival by multivariate analysis.

CONCLUSION

Hepatic resection including major-vessel resection/reconstruction for colorectal liver metastases can be performed with acceptable operative risk. However, such aggressive approaches are beneficial mainly in patients responding to effective prehepatectomy chemotherapy.

Surgical treatment of hepatocellular carcinoma

Local tumor control is still the most important consideration in the treatment of hepatocellular carcinoma (HCC). Surgical treatments, including liver resection and liver transplantation are, and will remain, the first-line therapeutic strategies for local control in patients with primary HCC. Although aggressive liver resection is often performed for advanced HCC in patients with a large tumor, multiple tumors, or tumors with vascular invasion, liver transplantation is the preferred option, after taking into consideration age and tumor-related factors, when there is poor liver functional reserve. Preventing deterioration in liver function is the second priority in the treatment of HCC. When performing liver resection, extensive removal of noncancerous liver parenchyma during lobectomy or hemihepatectomy, should be avoided as much as possible. Anatomic resection, which refers to systematic elimination of the main tumor with its minute metastases, preserves liver function and is highly recommended. A treatment algorithm based on published evidence is now available, which helps us decide on the most suitable therapeutic option for individual patients, depending on the tumor characteristics and liver functional reserve.

Prognostic value of concomitant resection of extrahepatic disease in patients with liver metastases of colorectal origin

BACKGROUND

Operative resection is the treatment of choice for colorectal liver metastasis. In the present study, we investigated the prognostic factors after hepatic resection, focusing on the concomitant resection of extrahepatic metastases.

METHOD

A retrospective cohort study was performed in 187 consecutive patients who had undergone initial hepatic resections for colorectal metastases using the Cox proportional hazards model.

RESULTS

The overall survival rates at 3, 5, and 10 years were 49%, 30%, and 22%, respectively. Hilar lymph node involvement (HLN), localized peritoneal seeding (P), and distant organ metastasis (M) were resected in addition to the liver metastases in 9, 13, and 21 patients, respectively. The P and M factors were related univariately to an unfavorable patient prognosis, but the HLN factor was not. In a multivariate regression analysis, the hazard ratios of these three factors of interest were 1.58 (HLN; 95% confidence interval 0.64-2.52, median survival 48 months), 2.12 (P; 1.38-2.85, 18 months), and 3.07 (M; 2.45-3.68, 19 months), respectively.

CONCLUSION

Aggressive operative resection for colorectal liver metastases yielded an acceptable long-term outcome. The presence of distant organ metastasis seems to be a contraindication for operative intervention and/or resection; although the number of patients enrolled in the present study was small, resection of localized peritoneal seeding or hilar lymph node involvement, in addition to the resection of the liver metastases, may benefit patient survival.

Liver resection for colorectal liver metastasis

At some point in the natural course of colorectal cancer up to 50% of patients will develop metastasis to the liver. Historically only 20% of these patients would have to be deemed resectable, with an intent to cure, at the time of presentation. But with recent improvements in cross-sectional imaging, chemotherapeutic agents and advances in the techniques of surgical resection the emphasis of resection has now changed to 'who is not resectable' as opposed to 'who is resectable'. There are few contraindications to liver resection on the proviso that the patient is fit enough. As a result of this paradigm shift, 5 year survival rates are approaching 60%. Historically liver resection was perceived as a formidable operation but now liver resection for CRLM is safe and specialist centres are reporting mortality rates of less than 1%. This review briefly covers the standard techniques currently employed and some of the recent innovations being developed to improve resectability.

Strategies to treat primary unresectable colorectal liver metastases

The liver is the most common site of metastases in patients with colorectal cancer (CRC), and hepatic metastases are responsible for fatalities in at least two thirds of patients with colorectal malignancy. However, the only available treatment associated with long-term survival in patients with CRC metastases is liver resection. While recent studies have shown that liver resection achieves a 5-year overall survival from 37% to 58%, only 10% to 20% of patients with colorectal liver metastases are eligible for resection. Pharmacologic developments and conceptual advances in chemotherapy, regional treatment, and aggressive surgical strategies have ultimately changed the current treatment of patients with primary unresectable liver metastases caused by CRC. Patients who were treated by only palliative chemotherapy a few years ago presently have a variety of strategies available to render their disease surgically resectable with the potential for long-term survival. These advances are the result of a strong collaboration between medical oncologists and surgeons. The development of new chemotherapy protocols that offer the potential for curative surgery with optimum timing within the natural history of this metastatic disease is a shared therapeutic challenge.

Hepatic resection for primary or secondary malignancies with involvement of the inferior vena cava: is this operation safe or hazardous?

BACKGROUND

This study evaluated surgical techniques and results of patients with tumors who had undergone liver resection with partial resection and reconstruction of the IVC.

STUDY DESIGN

We performed a retrospective analysis of all patients who underwent combined liver and IVC resection and reconstruction at a single institution. We identified 19 patients and two categories of tumors, primary (n = 8) and metastatic (n = 11). In 12 patients, a direct suture of the IVC was performed; in 3 patients a pericardium bovine patch was applied; in another 4 patients the IVC was replaced by PTFEt prosthesis. In nine patients, total hepatic vascular occlusion was required.

RESULTS

Perioperative mortality was 5.9%, related to technical complications and hepatic insufficiency. Postoperative morbidity was 57.9%. Median survival time was 32 months (range 3 to 125 months). The 1-, 2-, and 5-year cumulative survival rates were 78.9%, 68%, and 49.1%, respectively. Tumor recurrence appeared in 13 patients and was the main cause of death (55.5%). Among the seven patients suffering from hepatocellular carcinoma, three are still alive at 31, 60, and 125 months after resection. In this group, 1-, 2-, and 5-year survival rates were 71.4%, 57.1%, and 38.1%. Among the 11 patients resected for colorectal liver metastases, the 1-, 2-, and 5-year survival rates were 81.8%, 62.3%, and 51.9%, respectively.

CONCLUSIONS

Liver resection combined with IVC resection and reconstruction is a feasible procedure that can be performed with an acceptable operative risk leading to longterm outcome in selected patients.