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

Abstract

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.

Fig. 1

Extended right hepatectomy with left hepatic vein (LHV) reconstruction using interposition of an autologous external iliac vein graft (case 7 in Table 1). Initially, the patient’s tumor condition was diagnosed as unresectable because of massive multiple tumors predominantly in the right liver, with invasion of the right hepatic vein (RHV) and the trunk of the middle hepatic vein (MHV) and LHV (arrows on a). After seven courses of mFOLFOX6/panitumumab, the tumors shrank significantly, and the trunk of the MHV + LHV still was involved by the tumor (arrow on b). An external iliac vein interposition graft (asterisk) 5 cm long has been anastomosed between the distal stump of the LHV (white arrow) and the interior vena cava (IVC) orifice of the MHV + LHV trunk (black arrow on c). A computed tomography (CT) scan 12 months after hepatectomy shows the reconstructed LHV to be patent (asterisk on d). At this writing, the patient is alive without recurrence 24 months after the hepatectomy

Fig. 2

Partial resection of segments 4 and 8 associated with a large amount of hepatectomy of the anterior section and segment 7 (case 12 in Table 1). The ventral wall of the middle hepatic vein (MHV) and the left hepatic vein (LHV) is involved by the tumor occupying segments 4 and 8 (arrow on a). A significant amount of the anterior section and segment 7 must be resected for other tumors (red dotted lines) (b). The tumor in segments 4 and 8 was resected with the whole MHV and the anterior wall of the LHV (asterisk on c). The white arrow shows the remaining posterior wall of the LHV (c). The defect of LHV was reconstructed with an inferior mesenteric vein (IMV) patch graft stretched between the proximal orifice of the trunk of MHV + LHV and the distal orifice of the LHV, with four points-stay stitches (d). “Anterior” shows the large defect of the right anterior section (d). “Lateral” shows the left lateral section spared by LHV reconstruction (d)

Fig. 3

Cumulative overall survival rate after hepatectomy for colorectal liver metastasis according to major vascular reconstruction. The survival rate for the 15 patients who underwent hepatectomy with major vascular reconstruction was compared with that of 77 patients who did not in the same era. The two groups did not show a statistically significant difference