Extrahepatic right portal vein ligation allows parenchyma-sparing en bloc resection of segments 7, 8 and 4a for liver tumors engaging the right and middle hepatic veins

Charalampos Farantos, Nikolaos Arkadopoulos, Pantelis Vassiliu, Panagiotis Kokoropoulos, Nikolaos Economopoulos, Aggeliki Pandazi and Vassilis Smyrniotis

Chaidari, Greece

Extrahepatic right portal vein ligation allows parenchyma-sparing en bloc resection of segments 7, 8 and 4a for liver tumors engaging the right and middle hepatic veins

Charalampos Farantos, Nikolaos Arkadopoulos, Pantelis Vassiliu, Panagiotis Kokoropoulos, Nikolaos Economopoulos, Aggeliki Pandazi and Vassilis Smyrniotis

Chaidari, Greece

Right trisectionectomy for posterior liver tumors engaging the right and middle hepatic veins may lead to post-hepatectomy liver failure if the anticipated liver remnant is small. In such patients we developed a parenchymasparing one-step approach, that includes extrahepatic right portal vein ligation accompanied by en bloc resection only of segments 7, 8 and 4a and resection of the right and middle hepatic veins. The technique was applied in 3 patients with normal liver function, where according to the preoperative computed tomography the volume of segments 1, 2 and 3 ranged between 17% and 20% of the total liver volume. In all patients liver biochemistry improved rapidly postoperatively and a doubling of volume of segments 1, 2 and 3 was achieved by the third postoperative week, as extrahepatic right portal vein ligation ameliorated reperfusion injury of the remaining segments 5 and 6 and induced hypertrophy of segments 1, 2, 3 and 4b. There was no mortality or long-term complications. Patients are alive and free of disease 74, 50 and 17 months after the operation, respectively. We propose that the term "extended upper right sectionectomy" may be considered for the en bloc resection of segments 7, 8 and 4a, in future revisions of the Brisbane 2000 terminology of hepatic anatomy and resections.

(Hepatobiliary Pancreat Dis Int 2015;14:539-542)

liver trisectionectomy;

extrahepatic right portal vein ligation;

parenchyma-sparing hepatectomy

Introduction

Hepatectomy for posterior tumors engaging both the right and middle hepatic veins, necessitates resection of the abovementioned veins leading to right trisectionectomy (i.e. removal of segments 4-8). In cases where the remaining left lateral section (i.e. segments 2 and 3) is less than 20%-30% in normal and 30%-40% in diseased livers (steatotic, cirrhotic, post-chemotherapy) such an extended resection may lead to post-hepatectomy liver failure (PHLF).[1]To prevent PHLF, strategies to increase the remnant liver volume have been proposed, including mainly portal vein embolization (PVE),[2]and advanced liver partition and portal vein ligation (ALPPS).[3]PVE entails occlusion of the main portal vein branch ipsilateral to the tumor with a percutaneous transhepatic approach, inducing hypertrophy of the contralateral lobe. Hepatectomy follows 2-8 weeks after PVE. ALPPS is a two-step technique involving initially a laparotomy where right portal vein ligation and in situ splitting of the liver on the right of the falciform ligament is performed, leading to rapid hypertrophy of the left lateral section. Right trisectionectomy may follow after 5-30 days.

As an alternative to the previously mentioned techniques, we developed a parenchyma-sparing one-step approach that includes extrahepatic right portal veinligation (ERPVL) followed by en bloc resection only of segments 7, 8 and 4a together with resection of the right and middle hepatic veins. The technique was applied in 3 patients harboring posterior liver tumors that invaded both the right and middle hepatic veins.

Methods

Between January 2009 and November 2013, ERPVL followed by en bloc resection of segments 7, 8 and 4a was performed in 3 patients, for posterior tumors located in segments 7, 8 and 4a that invaded both the right and middle hepatic veins. The preoperative diagnosis was colorectal liver metastases (CRLMs) in 2 patients that had been operated for sigmoid cancer 3 years (patient 1) and 2 years (patient 2) before presenting with a liver tumor and intrahepatic cholangiocarcinoma in the third patient. All patients had normal preoperative liver function and absence of serious comorbidities. The 2 patients harboring CRLMs had been offered adjuvant chemotherapy after sigmoidectomy, consisting of 6 cycles of capecitabine (p.o.) and oxaliplatin (i.v.), while neither of the patients received neo-adjuvant chemotherapy before the hepatectomy. According to the preoperative computed tomography (CT) volumetry, the volume of segments 1, 2 and 3 in these patients ranged between 17% and 20% of the total liver volume.

Surgical technique

All the procedures were performed by the last author (SV), using the previously reported technique of selective hepatic vascular exclusion.[4]

The abdomen was entered via a bilateral subcostal incision. The liver ligaments were divided and tumor resectability was assessed with the aid of intraoperative ultrasonography (IOU). After the exact location of each liver lesion and particularly its relation to major vascular structures was precisely determined, the transection plane was designed. Then the liver was mobilized from the retrohepatic inferior vena cava taking care to preserve any accessory inferior right hepatic vein (present in one patient). The extrahepatic trunks of the three major hepatic veins were dissected free from the surrounding tissues. The hilar structures were also dissected and the right portal vein was doubly ligated extrahepatically with polypropylene 3-0. Care was taken to avoid damage to the right hepatic artery and right hepatic duct. Liver inflow control was attained by clamping the porta hepatis with a Satinsky clamp and liver outflow control by placing bulldog clamps at the trunks of the major hepatic veins. The liver parenchyma was then divided to the predetermined plane with a scalpel under IOU guidance, removing en bloc segments 7, 8 and 4a together with the invaded portion of the right and middle hepatic veins (Fig. 1). In one patient (patient 2) part of the right hemidiaphragm was also resected as it was infiltrated by the tumor. The stumps of the transected right and middle hepatic veins and all the orifices of vascular and biliary radicals found on the liver remnant were individually stitched with polypropylene 3-0. Any residual capillary bleeding was controlled by the Aquamantys® 9.5XL Bipolar Sealer (Medtronic Advanced Energy).

Fig. 1. Schematic diagram of the main steps of our proposed technique. Step 1: extrahepatic right portal vein ligation (inset) following mobilization of the liver; step 2: occlusion of the extrahepatic trunks of the right and middle hepatic veins; step 3: under occlusion of the porta hepatis and the major hepatic veins, en bloc resection of segments 7, 8 and 4a (along the red line).

Results

Patients characteristics, operative data and postoperative data are presented in Table. There was no mortality, while major morbidity consisting of ascites, pleural effusion and chest infection was observed in only one patient (patient 2) and was attributed to the concomitant diaphragmatic resection. The hospital stay was also prolonged in this patient due to the abovementioned complications (22 vs 9 days). In all patients liver biochemistry improved rapidly after the first postoperative week, as it was reflected by the values of aspartate aminotransferase on the second and seventh postoperative day. Also a doubling volume of segments 1, 2 and 3 was evident on CT volumetry that was performed on the third postoperative week. No long-term complications were recorded. Histological examination confirmed the preoperative diagnosis of CRLMs in two patients and cholangiocarcinoma in the third one. Excision margins were tumor-free and R0 resections were achieved in all patients. Patients are alive 74, 50 and 17 months after the hepatectomy, with no evidence of tumor recurrence.

Table. Characteristics, operative data and postoperative data of the patients

Discussion

Right trisectionectomy is the operation usually performed for posterior tumors engaging both the right and middle hepatic veins. If according to the preoperative CT the future liver remnant (segments 2 and 3) is anticipated to be less than 20%-30% in normal and 30%-40% in diseased liver, either PVE or ALPPS can be applied to prevent PHLF.[1-3]Although PVE is the most popular and standardized procedure, its effect is partly jeopardized by the formation of collaterals between the two liver lobes. Also as it causes a compensatory increase in the hepatic artery flow, concerns exist about tumor progression during the 2-8 week interval between PVE and hepatectomy.[5,6]ALPPS prevents the formation of collaterals and induces faster hypertrophy of the future liver remnant compared to PVE, but it is associated with a high morbidity (up to 68%) and mortality (9%-22%), although recently a mortality as lower as 0-9% has been reported in patients with CRLMs.[3,7,8]

Fig. 2. A 53-year-old man (patient 3) with intrahepatic cholangiocarcinoma measuring 6.5×5.4×9.0 cm, that was offered en bloc resection of segments 7, 8 and 4a with ERPVL. A: Preoperative CT scan (liver dome view) showing the tumor invading both the right and middle hepatic veins. The black lines represent the sagittal and transverse diameter of the tumor at this level (6.5×4.5 cm); B: Postoperative CT scan (3rd week) demonstrating hypertrophy of segments 2, 3, 4b and atrophy of segments 5 and 6 that appear hypodense; C: Preoperative CT scan at liver hilum level showing the tumor adjacent to the left portal vein. The black lines represent the sagittal and transverse diameter of the tumor at this level (5.3×5.4 cm); D: Postoperative CT scan (3rd week) at the same level with Fig. 1C (liver hilum) demonstrating hypertrophy of segments 1, 2, 3 and 4b leading to doubling volume of segments 1, 2, 3 (41.5% of total liver volume postoperatively vs 20% preoperatively) and atrophy of segments 5 and 6. The white arrow indicates the right portal vein stump.

In the 3 patients presented in this article, a parenchyma-sparing en bloc resection of segments 7, 8 and 4a together with resection of the right and middle hepatic veins was performed for posterior tumors invading both of these veins. ERPVL was performed before segments 7, 8 and 4a resection in order to ameliorate reperfusion injury of segments 5 and 6 by reducing portal inflow and to induce hypertrophy of segments 1, 2, 3 and 4b. After ERPVL, segments 5 and 6 were perfused only by the right hepatic artery and drained by any accessoryright hepatic vein or by hepatic vein collaterals. No case of venous congestion of segments 5 and 6 was noted intraoperatively. The experience gained from the surgical treatment of portal hypertension with total portocaval shunts shows that hepatic function can be preserved even if portal flow is completely diverted.[9]Therefore, in the 3 cases presented, it seems that segments 5 and 6 undertake an auxiliary function by providing a critical hepatocyte mass during the first week after hepatectomy. Then even if atrophy of segments 5 and 6 occurs due to poor inflow and outflow, the hypertrophied segments 1, 2, 3 and 4b are capable of satisfying the metabolic demands of the remaining liver. This assumption is supported by the data in the present article, as liver biochemistry improved rapidly after the first postoperative week and a doubling volume of segments 1, 2 and 3 was achieved by the third postoperative week (Table, Fig. 2). There were also no long-term complications in any of the patients despite atrophy of segments 5 and 6 that was evident on follow-up CT scans. ERPVL seems to be of paramount importance in achieving en bloc resection of segments 7, 8 and 4a, as it induces hypertrophy of segments 1, 2, 3 and 4b like PVE and also permits better matching between inflow and outflow of segments 5 and 6. If ERPVL is not performed before the en bloc resection of segments 7, 8 and 4a and the resection of the right and middle hepatic veins, the resulting portal overflow of the poorly drained segments 5 and 6 may lead to severe congestion of these segments and catastrophic intraoperative bleeding.

The safety and the good oncological results of the proposed technique are supported by the fact that there was no mortality and all patients are still alive and free of disease 74, 50 and 17 months after the hepatectomy. It is an one-step approach that salvages the hepatic parenchyma and can be applied even if the future liver remnant (segments 1, 2 and 3) is anticipated to be less than 20% in normal liver (17%-20% according to the presented data). It combines the advantages of PVE and ALPPS, without the potentially hazardous post-PVE interval and the second laparotomy of ALPPS. Following the principles of the International Hepato-Pancreato-Biliary Association terminology for liver resections, we propose that the term "extended upper right sectionectomy" may be considered for the en bloc resection of segments 7, 8 and 4a (Fig. 1).[10]

In conclusion, ERPVL allows a safe, parenchyma-sparing and oncologically adequate en bloc resection of segments 7,8 and 4a for posterior hepatic tumors in patients with normal liver function, although treatment of a larger number of patients is needed to establish its clinical benefit.

Acknowledgements: We thank Vassiliki Frangiadaki, student in

Athens University Medical School, for the artwork of Fig. 1.

Contributors: FC, AN and SV were enrolled in the conception and design of the study, VP, KP, EN and PA in the acquisition of the data and FC, AN and SV in the analysis and interpretation of the data. FC and AN drafted the manuscript, while PA and SV revised it critically. FC is the guarantor.

Funding: None.

Ethical approval: Not needed.

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Accepted after revision August 10, 2015

10.1016/S1499-3872(15)60421-0

Author Affiliations: Fourth Department of Surgery (Farantos Ch, Arkadopoulos N, Vassiliu P, Kokoropoulos P and Smyrniotis V); Second Department of Radiology (Economopoulos N); and Second Department of Anesthesiology (Pandazi A), Athens University Medical School, Attikon University Hospital, Chaidari 12462, Greece

Charalampos Farantos, MD, Fourth Department of Surgery, Athens University Medical School, Attikon University Hospital, 1 Rimini Street, Chaidari 12462, Greece (Tel: +30-210-5831364; Fax: +30-210-5326385; Email: chfarantos@yahoo.gr)

© 2015, Hepatobiliary Pancreat Dis Int. All rights reserved.

Published online September 17, 2015.

April 28, 2015