Future liver remnant hypertrophy rate in portal vein embolization before left trisectionectomy: a retrospective cohort study

PURPOSE

Reports on the future liver remnant (FLR) hypertrophy rate in patients undergoing portal vein embolization (PVE) before left trisectionectomy are sparse. This study aimed to assess the FLR hypertrophy rate in patients undergoing PVE before left trisectionectomy.

METHODS

Between January 2010 and June 2021, 30 patients (22 men and eight women; mean age, 65.7 years) underwent PVE, mainly using gelatin sponge, before left trisectionectomy. The preoperative diagnosis was cholangiocarcinoma in 28 patients and colorectal liver metastases in two patients. The FLR hypertrophy rate, increase in the FLR volume (FLRV) ratio (the ratio of the FLRV to the total liver volume), and complications were evaluated. The patients were further divided into two groups: one group of patients with left portal vein stenosis or occlusion before PVE (n = 12) and another without left portal vein stenosis or occlusion before PVE (n = 18). The FLR hypertrophy rate and increase in the FLRV ratio were compared between the two groups.

RESULTS

The FLR hypertrophy rate and increase in the FLRV ratio were 31.3% and 6.9%, respectively. One major complication, cholangitis, developed; however, its association with PVE was unclear. The difference in the FLR hypertrophy rate and the increase in the FLRV ratio between the two groups of patients was statistically insignificant.

CONCLUSION

PVE before left trisectionectomy is effective in achieving FLR hypertrophy. PVE before left trisectionectomy was equally effective in patients with left portal vein stenosis or occlusion as compared to those without. The complication rates were acceptable.

A successfully resected case of left trisectionectomy with arterio-portal combined resection for advanced cholangiocarcinoma

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In case of cholangiocarcinoma invading hilar vessels, adequate simulations and expert skills are required to achieve R0 resection.

Introduction

The present case report demonstrated the successfully radical operation (R0) for the highly advanced cholangiocarcinoma involving hilar hepatic arteries and portal vein, The careful preoperative diagnosis to define the adequate resection area and the expert operation was achieved without postoperative severe complications.

Presentation of case

A 55-year-old male was admitted to our hospital with obstructive jaundice, and the perihilar cholangiocarcinoma (PC) was found. At the time of finding PC, enhanced computed tomography showed the widely extension and involved the surrounding right hepatic artery (RHA) and bilateral portal veins (PV). According to extension of PC, left trisectionectomy combined resection of RHA and PV trunk was scheduled. By supporting plastic surgeon’s procedure, the scheduled R0 operation could be achieved and the patient was discharged without any severe complication but delayed intrahepatic abscess formation. After abscess drainage, he could immediately recovered and tumor relapse was not observed for a couple of months. By carefully preoperative examination, a complicated operation was successfully completed.

Discussion

The major hepatectomy with arterio-portal resections and anastomosis for advanced has been challenged at the high-volume center and the improvement of survival seemed to be obtained and, however, operative risk is still remained. This operation could be achieved by the expert surgeons under precise planning or management.

Conclusion

The role of HBP surgeons is to challenge aggressive surgery even for patients with highly advanced local extension of PC.

The Pitfalls of Left Trisectionectomy or Central Bisectionectomy for Biliary Cancer: Anatomical Classification Based on the Ventral Branches of Segment VI Portal Vein Relative to the Right Hepatic Vein

BACKGROUNDS

Some patients have P6a running on the ventral side (Ventral-P6a), relative to the right hepatic vein (RHV).

STUDY DESIGN

Forty-one patients who underwent left trisectionectomy or central bisectionectomy for biliary cancer were enrolled. We compared the anatomical features using 3D images and surgical outcomes between patients with Ventral-P6a (n = 17) and those with P6a running on the dorsal side relative to the RHV (Dorsal-P6a; n = 25). Moreover, the liver volume by hand-tracing 2D axial images was compared to the volume calculated using the 3D images.

RESULTS

The frequency of complete exposure of RHV on the transection plane was less in Ventral-P6a (12 vs. 76%; p < 0.001), and the frequency of supraportal type of right posterior hepatic artery (RPHA, 29 vs. 4%, p = 0.020), the presence of inferior RHV (47 vs. 12%, p = 0.011), and the angle between the transection plane of segment VI and VII (S6-S7angle, 29.0° vs. 4.9°; p < 0.001) were greater in Ventral-P6a than in Dorsal-P6a. In Dorsal-P6a, the volume of posterior section calculated using 2D images was greater than that calculated using 3D images (404 vs. 370 mL; p = 0.004). The incidence of daily diuretic administration in Dorsal-P6a was greater than in Ventral-P6a (88 vs. 54%, p = 0.035).

CONCLUSION AND RELEVANCE

In Ventral-P6a, the complete exposure of RHV was rare in left trisectionectomy or central bisectionectomy. Surgeons should preoperatively recognize the course of RPHA, the presence of inferior RHV, and the S6-S7angle. In Dorsal-P6a, the volume of posterior section, which tended to be overestimated using 2D images, was smaller than that in Ventral-P6a.

Major hepatectomy using the glissonean approach in cases of right umbilical portion

Right umbilical portion (RUP) is a rare congenital anomaly associated with anomalous ramifications of the hepatic vessels and biliary system. As such, major hepatectomy requires a careful approach. We describe the usefulness of the Glissonean approach in two patients with vessel anomalies, such as RUP. The first patient underwent a right anterior sectionectomy for intrahepatic cholangiocarcinoma. We encircled several Glissonean pedicles that entered the right anterior section along the right side of the RUP. We temporarily clamped each pedicle, confirmed the demarcation area, and finally cut them. The operation was performed safely and was successful. The second patient underwent a left trisectionectomy for perihilar cholangiocarcinoma. We secured the right posterior Glissonean pedicle. The vessels in the pedicle were preserved, and the other vessels and contents were resected. Identifying the vessels for preservation facilitated the safe lymphadenectomy and dissection of the vessels to be resected. We successfully performed the operation.