Choice of approach for hepatectomy for hepatocellular carcinoma located in the caudate lobe: Isolated or combined lobectomy?

An inferior vena cava-priority approach in laparoscopic isolated hepatic caudate lobectomy

PURPOSE

Laparoscopic isolated caudate lobectomy is still a challenging operation for surgeons. The access route of the operation plays a vital role during laparoscopic caudate lobectomy. There are few references regarding this technique. Here, we introduce a preferred inferior vena cava (IVC) approach in laparoscopic caudate lobectomy.

METHODS

Twenty-one consecutive patients with caudate hepatic tumours between June 2016 and December 2021 were included in this study. All of them received laparoscopic caudate lobectomy involving an IVC priority approach. The IVC priority approach refers to prioritizing the dissection of the IVC from the liver parenchyma before proceeding with the conventional left or right approach. It emphasizes the importance of the IVC dissection during process. Clinical data, intraoperative parameters and postoperative results were evaluated. Sixteen patients were performed pure IVC priority approach, while 5 patients underwent a combined approach. We subsequently compared the intraoperative and postoperative between the two groups.

RESULTS

All 21 patients were treated with laparoscopic technology. The operative time was 190.95 ± 92.65 min. The average estimated blood loss was 251.43 ± 247.45 ml, and four patients needed blood transfusions during the perioperative period. The average duration of hospital stay was 8.43 ± 2.64 (range from 6.0 to 16.0) days. Patients who underwent the pure inferior vena cava (IVC) approach required a shorter hepatic pedicle clamping time (26 vs. 55 min, respectively; P < 0.001) and operation time (150 vs. 380 min, respectively; P = 0.002) than those who underwent the combined approach. Hospitalization (7.0 vs. 9.0 days, respectively; P = 0.006) was shorter in the pure IVC group than in the combined group.

CONCLUSIONS

Laparoscopic caudate lobectomy with an IVC priority approach is safe and feasible for patients with caudate hepatic tumours.

Survival outcomes after caudate lobectomy for hepatocellular carcinoma: systematic review and meta-analysis

BACKGROUND

Caudate lobectomy (CLB) remains the most effective treatment for caudate lobe hepatocellular carcinoma (CL-HCC). However, there is controversy regarding the survival after CLB. This meta-analysis aims to investigate the survival outcomes following CLB for the treatment of CL-HCC.

METHODS

In line with PRISMA and MOOSE guidelines, a search for all eligible studies was performed. The pooled estimates of survival rates and hazard ratios (HRs) with their 95% confidence intervals (CIs) were calculated using fixed- or random-effects models.

RESULTS

Sixteen studies comprising 864 patients met the inclusion criteria. The pooled estimates of 3- and 5-year overall survival (OS) rates were 62.3% and 42.9% respectively and the pooled estimate of 3- and 5-year recurrence-free survival (RFS) rates were 39.3% and 24.4% respectively. CL-HCC showed inferior OS (HR:1.39, 95% CI: 0.91-1.88, P < 0.001) and RFS (HR:1.33, 95% CI: 1.10-1.56, P < 0.001) than other sites HCC. Isolated CLB showed better OS (HR:0.9, 95% CI:0.39-1.41, p < 0.001) and RFS (HR:0.76, 95% CI: 0.03-1.5, P = 0.04) than combined CLB.

CONCLUSIONS

The survival outcomes for CL-HCC after CLB are lower compared to other sites HCC. Isolated CLB offers better survival outcomes compared to combined CLB. However, choosing isolated or combined approaches should be prioritized according to patient and tumour characteristics.

A Double Suspension Technique for Laparoscopic Isolated Caudate Lobectomy

Background: Laparoscopic isolated caudate lobectomy is still a challenging procedure for hepatobiliary surgeons because of its deep location and narrow operating space. Hilar exposure and adequate operation space play an important role during laparoscopic caudate lobectomy. Very few references are available on this technique, and in this study, we present a new suspension technique to assist laparoscopic caudate lobectomy. Materials and Methods: The data of patients with caudate hepatic tumors who underwent laparoscopic isolated caudate lobectomy with or without the double suspension technique at the Eastern Hepatobiliary Surgery Hospital were retrospectively analyzed. Results: A total of 25 patients underwent laparoscopic isolated caudate lobectomy at Eastern Hepatobiliary Surgery Hospital between June 2016 and March 2022. Eight patients had perioperative complications, and no patient died within 30 days after surgery. There were no significant differences between the two groups in terms of conversion rate (8.3% versus 7.7%; P = .954), complication rate (25.0% versus 38.5%; P = .480), length of stay (8.0 [6.0-11.0] days versus 9.0 [6.0-19.0] days; P = .098), and postoperative liver function changes. Patients who underwent resection in the suspension group had shorter operation time (154.9 ± 44.3 minutes versus 224 ± 86.3 minutes; P = .018), inferior vena cava dissection time (30.1 ± 5.4 minutes versus 44.8 ± 7.4 minutes; P < .001), and less bleeding (125.0 [20-800.0] mL versus 350 [80-850.0] mL, P = .011). Conclusions: This double suspension technique is a safe and feasible method to assist laparoscopic caudate lobectomy. It provides clear exposure and adequate surgical space, thereby shortening the operation time and reducing intraoperative blood loss.

Laparoscopic versus open caudate lobe liver resections: a 1:2 propensity score-matched controlled study based on a single institution experience

BACKGROUND

Despite the wide use of laparoscopy for liver resection, laparoscopic caudate lobe resections(L-CLR) remain technically challenging, only attempted by experts in the field. The primary objective of this study was to determine the safety and compare the perioperative outcomes of L-CLR with O-CLR based on our single institution experience in a 1:2 propensity score-matched controlled study based on our single institution experience.

METHODS

Between 2004 and 2020, 67 consecutive patients who underwent CLR at Singapore General Hospital were identified. Propensity score matching (PSM) of laparoscopic versus open caudate lobe resections(O-CLR) was performed in a 1:2 ratio with no replacements using nearest neighbour matching method.

RESULTS

L-CLR was associated with a significantly decreased median blood loss (150 mL versus 500 mL, P = 0.001) and a decreased median post-operative stay (3 days versus 7.5 days, P = <0.01) in the unmatched cohorts. After 1:2 propensity score matching, these results were again demonstrated with a significantly lower blood loss (150 mL versus 400 mL, P = 0.016) and a shorter postoperative stay (3 days versus 7 days, P = <0.01) in favour of L-CLR. 30-day readmission and major morbidity (Clavien-Dindo grade > 2) rates were all in favour of L-CLR as well but could not reach statistical significance.

CONCLUSION

L-CLR can be safely performed by experienced surgeons. It is associated with decreased blood loss and shorter perioperative stay compared to O-CLR.

Validity of the Algorithm for Liver Resection of Hepatocellular Carcinoma in the Caudate Lobe

BACKGROUND

We aimed to validate our algorithm for resecting Hepatocellular carcinoma (HCC) in the caudate lobe based on tumor location, tumor size, and indocyanine green clearance rate.

METHODS

Patients who underwent curative resections for solitary HCC in the caudate lobe were included. The surgical outcomes of patients with HCC in the caudate lobe were compared with those of patients with HCC in other sites of the liver.

RESULTS

After one-to-one matching, the caudate-lobe group (n = 150) had longer operation time, greater amount of bleeding, lower weight of resected specimens, and shorter distance between tumor and resection line than the other-sites group (n = 150), but the complication rates were not different between the groups (38.0% vs. 34.1%, P = 0.719). After a median follow-up period of 3.0 years (range, 0.3-16.2 years), the median overall survivals were 6.5 (95% confidence interval [CI], 5.3-7.9) and 7.5 years (95% CI, 6.3-9.7) in the caudate-lobe and other-site groups, respectively (P = 0.430). Median recurrence-free survivals in the caudate-lobe group (1.9 years; 95% CI, 1.4-2.7) had a tendency to be shorter than those in the other-sites group (2.3 years; 1.7-3.4) (P = 0.052).

CONCLUSIONS

Patients' survival and complication rates in the caudate-lobe group were comparable to those in the other-sites group; therefore, our algorithm for resecting HCC in the caudate lobe is of clinical use.

Surgical Strategy for Resecting Hepatocellular Carcinoma in the Caudate Lobe: Isolated or Combined Lobectomy? A Single-Center Study and Meta-Analysis

Background

Resection of hepatocellular carcinoma (HCC) originating in the caudate lobe remains challenging, while the optimal extent of resection is debated. We aimed to evaluate the relative benefits of combined caudate lobectomy (CCL) versus isolated caudate lobectomy (ICL) for caudate HCC.

Methods

Patients who underwent curative-intent resection for caudate HCC between January 2010 and December 2018 were identified from a single-center database. Surgical outcomes of the two strategy groups were analyzed before and after propensity score matching. A systematic review with meta-analysis was also performed to compare outcomes of CCL versus ICL for caudate HCC.

Results

A total of 28 patients were included: 11 in the CCL and 17 in the ICL group. Compared with ICL, the CCL group contained patients with larger tumors and a higher incidence of vascular invasion. After propensity score matching, 6 pairs of patients were selected. In the well-matched cohort, CCL demonstrated significantly improved recurrence-free survival (RFS) (P = 0.047) compared with ICL; no significant differences were noted for overall survival (OS), operation time, blood loss and morbidity rate. A total of 227 patients from nine eligible studies and ours were involved in the systematic review. Meta-analysis revealed that CCL provided better RFS (hazard ratio 0.54, 95% confidence interval 0.31–0.92) than ICL; no significant differences were observed in OS, operation time, blood loss and morbidity rate.

Conclusion

CCL confers superior RFS over ICL without compromise of perioperative outcomes and should be prioritized for patients with caudate HCC when feasible, especially for those with large-sized tumors.

Algorithm for Resecting Hepatocellular Carcinoma in the Caudate Lobe

OBJECTIVE

To propose an algorithm for resecting hepatocellular carcinoma (HCC) in the caudate lobe.

BACKGROUND

Owing to a deep location, resection of HCC originating in the caudate lobe is challenging, but a plausible guideline enabling safe, curable resection remains unknown.

METHODS

We developed an algorithm based on sublocation or size of the tumor and liver function to guide the optimal procedure for resecting HCC in the caudate lobe, consisting of 3 portions (Spiegel, process, and caval). Partial resection was prioritized to remove Spiegel or process HCC, while total resection was aimed to remove caval HCC depending on liver function.

RESULTS

According to the algorithm, we performed total (n = 43) or partial (n = 158) resections of the caudate lobe for HCC in 174 of 201 patients (compliance rate, 86.6%), with a median blood loss of 400 (10-4530) mL. Postoperative morbidity (Clavien grade ≥III b) and mortality rates were 3.0% and 0%, respectively. After a median follow-up of 2.6 years (range, 0.5-14.3), the 5-year overall and recurrence-free survival rates were 57.3% and 15.3%, respectively. Total and partial resection showed no significant difference in overall survival (71.2% vs 54.0% at 5 yr; P = 0.213), but a significant factor in survival was surgical margin (58.0% vs 45.6%, P = 0.034). The major determinant for survival was vascular invasion (hazard ratio 1.7, 95% CI 1.0-3.1, P = 0.026).

CONCLUSIONS

Our algorithm-oriented strategy is appropriate for the resection of HCC originating in the caudate lobe because of the acceptable surgical safety and curability.

High dorsal resection for hepatocellular carcinoma: surgical plane and outcomes

High dorsal resection (HDR) of the liver is a systematic resection technique for hepatocellular carcinoma (HCC) arising in the caudate lobe. HDR is rarely performed, as the procedure requires a high level of operative skill, knowledge of liver anatomy and is performed in patients with limited hepatic function. Between 2002 and 2012, we performed HDR on 9 patients. The median operation time was 534 min (range, 349-903 min), and the median blood loss volume was 430 mL (range, 94-4,530 mL). The severe morbidity rate was 11.1%, but there was no operative mortality, and the median hospitalization was 13 days (range, 8-93 days). The overall survival was 49.7 months (range, 3.1-89.0 months). Despite the hard-to-approach anatomic location, HDR can be carried out safely with good survival compared to other segments.

Laparoscopic isolated caudate lobe resection

Previously, isolated caudate lobectomy was rarely performed and the caudate lobe was usually resected along with other segments. Isolated caudate lobe resection is a challenging procedure even for an experienced surgeon. Our aim was to evaluate the feasibility, safety and outcomes of laparoscopic isolated caudate lobectomy and to compare these with the open technique. We retrospectively analyzed 21 patients who underwent isolated caudate lobectomy between January 2005 and December 2018 at Seoul National University Bundang Hospital. Patients who underwent either anatomical or non-anatomical resection of the caudate lobe were included. Patients were divided into two groups according to whether they underwent laparoscopic or open surgery. Intra-operative and postoperative outcomes were compared with a median follow-up of 43 months (4–149). A total of 21 patients were included in the study. Of these, 12 (57.14%) underwent laparoscopic and nine (42.85%) underwent open caudate lobectomy. Median operation time (204.5 vs. 200 minutes, p = 0.397), estimated blood loss (250 vs. 400 ml, p = 0.214) and hospital stay (4 vs. 7 days, p = 0.298) were comparable between laparoscopy and open group. The overall post operative complication rate was similar in both groups (p = 0.375). The 5-year disease free survival rate (42.9% vs 60.0%, p = 0.700) and the 5-year overall survival rate (76.2% vs 64.8%, p = 0.145) was similar between laparoscopy and open group. Our findings demonstrate that with increasing surgical expertise and technological advances, laparoscopic isolated caudate lobectomy can become a feasible and safe in selected patients.

Prognoses and Clinicopathological Characteristics for Hepatocellular Carcinoma Originating from the Caudate Lobe After Surgery

BACKGROUND

The aim was to evaluate the prognoses and clinicopathological characteristics of solitary hepatocellular carcinoma (HCC) originating from the caudate lobe (HCC-CL).

METHODS

We analyzed 584 patients with a solitary tumor <10 cm from January 1990 to November 2014. Patients were classified into a caudate lobe group (CL; n = 39) and a non-caudate lobe group (NCL; n = 545). We investigated the prognoses and clinicopathological characteristics of solitary HCC-CL. We compared the surgical procedures performed in these cases.

RESULTS

HCC-CL had a similar rate of portal venous invasion (PVI) as HCC-NCL (21% vs. 19%); however, the frequency of tumor thrombus at the first branch of the portal vein (PV) or extension to the trunk or the opposite side of the PV was significantly higher in HCC-CL (8% vs. 2%). HCC-CL had similar OS rates compared to HCC-NCL; however, HCC-CL showed significantly poorer RFS. Although there were no significant differences among the three surgical procedures, blood loss and complication rates tended to be higher in cases who underwent an isolated caudate lobectomy. Tumor size ≥5 cm, PVI, and liver fibrosis or cirrhosis (LF or LC) were independent unfavorable factors for both OS and RFS. PIVKA-II ≥120 mAU/ml was an independent unfavorable factor for RFS.

CONCLUSION

HCC-CL presented a poorer RFS rate. Patients with a tumor size ≥5 cm, PIVKA-II ≥120 mAU/ml, portal venous invasion, and LF or LC should be diligently followed up as these cases have a high risk of recurrence.

Long-term complete response after transcatheter arterial chemoembolization and stereotactic body radiation therapy in a patient with hepatocellular carcinoma at the caudate lobe

It is expected that a combination of transcatheter arterial chemoembolization (TACE) with stereotactic body radiation therapy (SBRT) may induce synergistic therapeutic effects in hepatocellular carcinoma (HCC), which would result in a high rate of complete therapeutic response. In this study, we present the 5-year clinical course of a patient who had HCC at the caudate lobe, which was treated with TACE and SBRT. A 53-year-old male was diagnosed with an 8 cm-sized HCC at the caudate lobe with compression of the inferior vena cava (IVC). For fear of pulmonary metastasis, we decided to perform sequential TACE-radiotherapy instead of upfront hepatectomy, although the tumor appeared resectable. The first session of TACE, SBRT with 12 fractions, and the second session of TACE were sequentially performed. The patient was administered metformin for chemoprevention. Over the course of a 5-year follow-up, there was no evidence of HCC recurrence. We reported the clinical sequence of a patient showing complete therapeutic response of HCC at the caudate lobe after a combination of TACE and radiotherapy. This type of combined locoregional treatment can be a therapeutic option for HCC at the caudate lobe with marginal resectability.

Isolated caudate lobectomy: Left-sided approach. Case reports

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The options of treatment for caudate tumors are presented.

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Treatment of caudate tumors by left-sided approach is proposal.

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Better results with left-sided approach are discussed.

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Selection of patients with tumors in caudate lobe for left-sided approach is important.

Introduction

The caudate lobe is a distinct liver lobe and surgical resection requires expertise and precise anatomic knowledge. Left-sided approach was described for resection of small tumors originated in the Spiegel lobe but now the procedure has been performed even for tumors more than five centimeters. The aim of this study is to present three cases of tumor of caudate lobe underwent isolated lobectomy by left-sided approach.

Presentation of case

Three patients with metastasis of colorectal cancer, carcinoma hepatocellular and metastasis of neuroendocrine tumor underwent resection. After modified Makuuchi incision, early control of short hepatic e short portal veins before hepatectomy was performed. The operative time was 200, 270 and 230 min respectively. No blood transfusion was used and no postoperative complications were observed. The length of stay was 7, 11 and 5 days respectively.

Discussion

Some approaches have been described to access and resect tumors of the caudate lobe, including the left-sided approach, right-sided approach, combined left- and right-sided approach and the anterior transhepatic approach. For liver resection in patients with malignant disease, parenchymal preservation is important in order to avoid postoperative liver failure or due to the risk of second hepatectomy. In these patients isolated caudate lobectomy is a safe option.

Conclusion

Isolated caudate lobectomy is a feasible procedure. Left-sided approach can be preformed even for tumors larger than 5 cm.

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.

Management of hepatocellular carcinoma rupture in the caudate lobe

AIM: To demonstrate that caudate lobectomy is a valid treatment in cases of hepatocellular carcinoma (HCC) rupture in the caudate lobe based on our experience with the largest case series reported to date.

METHODS: A retrospective study of eight patients presenting with spontaneous rupture and hemorrhage of HCC in the caudate lobe was conducted. Two patients underwent ineffective transarterial embolization preoperatively. Caudate lobectomy was performed in all eight patients. Bilateral approach was taken in seven cases for isolated complete caudate lobectomy. Left-sided approach was employed in one case for isolated partial caudate lobectomy. Transarterial chemoembolization was performed postoperatively in all patients.

RESULTS: Caudate lobectomy was successfully completed in all eight cases. The median time delay from the diagnosis to operation was 5 d (range: 0.25-9). Median operating time was 200 min (range: 120-310) with a median blood loss of 900 mL (range: 300-1500). Five patient remained in long-term follow-up, with one patient becoming lost to follow-up at 3 years and two patients currently alive at 7 and 19 mo. One patient required reoperation due to recurrence. Gamma knife intervention was performed for brain metastasis in another case. Two patients survived for 10 and 84 mo postoperatively, ultimately succumbing to multiple organ metastases.

CONCLUSION: Caudate lobectomy is the salvage choice for HCC rupture in the caudate lobe. Local anatomy and physiologic features of the disease render caudate lobectomy a technically difficult operation. Postponement of surgical intervention is thus recommended while the rupture remains hemodynamically stable until an experienced surgeon becomes available. Prognosis is confounded by numerous factors, but long-term survival can be expected in the majority of cases.

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.

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.