Hepatic vein reconstruction for resection of hepatic tumors

Abstract

Summary background data: Involvement of the hepatic veins requiring reconstruction has traditionally been considered a contraindication to resection for advanced tumors of the liver because the surgical risks are high and the long-term prognosis poor. Recent advances in liver surgery gleaned from split and live donor liver transplantation that necessitate hepatic vein reconstruction can be applied to hepatic resection in some cases.

Methods: Sixteen patients who underwent hepatic resection requiring hepatic vein reconstruction from 1996-2001 were reviewed. The mean age was 43 years (range 2-61). Nine patients were resected for hepatocellular carcinoma (HCC), five patients for colorectal metastases, and one patient each for hepatoblastoma and cholangiocarcinoma. In six patients with HCC and cirrhosis, the right hepatic vein was reconstructed to provide venous outflow to liver segments not adequately drained by a remaining major hepatic vein. Four of these six patients required the use of Gore-Tex (W. L. Gore & Associates, Inc., Newark, DE) interposition grafts. In the 10 other cases the entire venous outflow from the remnant liver was reconstructed or reimplanted into the inferior vena cava primarily (n = 8) or using segments of the portal vein from the resected side of the liver as a graft (n = 2). Ex-vivo procedures with the use of veno-venous bypass were required in two cases and in-situ cold perfusion of the liver was used in one case.

Results: There were two perioperative deaths (12%). One patient died of liver failure 3 weeks after right trisegmentectomy with reconstruction of the left hepatic vein and one patient died at 3 months after resection due to sepsis from a segment of small bowel that perforated into a diaphragmatic hernia. Four patients had evidence of postoperative liver failure that resolved with supportive management and one patient required temporary dialysis. All vascular reconstructions were patent at last followup. With median followup of 23 months, 3 patients have died of recurrent malignancy at 14, 18 and 30 months, while an additional patient went on to die of progressive liver failure at 22 months. Actuarial 1 and 3 year survival was 88% and 50% respectively.

Conclusion: Hepatic vein involvement by hepatic malignancy does not necessarily preclude resection. Liver resection with reconstruction of the hepatic veins can be performed in selected cases. The increased risk associated with the procedure appears to be balanced by the possible benefits, particularly when the lack of alternative curative approaches is considered.

Figure 1. CT scan demonstrating colorectal metastases involving all 3 hepatic veins (case 2).

Figure 2. 8 mm ringed Gore-Tex graft used to reconstruct the right hepatic vein after resection of segments 7, part of 8, and 5.

Figure 3. Tumor located mainly in the left lobe but involving all three hepatic veins (A) can be resected with adequate margin by left trisegmentectomy and reconstruction of the right hepatic vein (B). In this diagram a portal vein graft from the resected side of the liver has been used for reconstruction of the right hepatic vein.

Figure 4. Tumor located mainly in the right lobe but involving all 3 hepatic veins (A) can be resected with adequate margin by right trisegmentectomy and reconstruction of the left hepatic vein (B, C).

Figure 5. Actuarial survival of 16 patients undergoing hepatic resection with hepatic vein reconstruction.