Better surgical treatment method for hepatocellular carcinoma with portal vein tumor thrombus

Abstract

Hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) is a disease that is not uncommon, but the treatments vary drastically between Eastern and Western countries. In Europe and America, the first line of treatment is systemic therapy such as sorafenib and the surgical treatment is not a recommend option. While an increasing number of studies from China and Japan have suggested that surgical treatment results in better outcomes when compared to transcatheter arterial chemoembolization (TACE), sorafenib, or other nonsurgical treatments, and two classification systems, Japanese Vp classification and Chinese Cheng's classification, were very useful to guide the surgical treatment. We have also found that surgical treatment may be more effective, as we have performed surgical treatment for HCC-PVTT patients over a period of approximately 15 years and achieved good results with the longest surviving time being 13 years and onward. In this study, we review the efficacy and principles of current surgical treatments and introduce our new, more effective surgical technique named "thrombectomy first", which means the tumor thrombus in the main portal vein, the bifurcation or the contralateral portal vein should be removed prior to liver resection. Thus, compression and crushing of PVTT during the operation could be avoided and new intrahepatic metastases caused by tumor thrombus to the remnant liver minimized. The new technique is even beneficial to the prognosis of Cheng's classification Types III and IV PVTT. The vital tips and tricks for the surgical approach are described.

Keywords: Hepatocellular carcinoma; Portal vein tumor thrombus; Surgery; Thrombectomy first.

Figure 1

The “thrombectomy first” approach. A: The right hepatic artery (RHA) was isolated and dissected. B: The right hepatic duct (RHD) was isolated and dissected. C: The left portal vein (LPV), right portal vein (RPV) and the main portal vein (PV) were clearly revealed by dissecting the hepatic artery-hepatic duct (HA-HD) flap. D: The tumor thrombus in the RPV and main portal vein (MPV) was extracted. E: The tape of LPV and PV were both released to flush the remnant tumor thrombus. RHA: Right hepatic artery; RHD: Right hepatic duct; LPV: Left portal vein; RPV: Right portal vein; PV: Portal vein; MPV: Main portal vein; HA-HD: Hepatic artery-hepatic duct.

Figure 2

The hepatic artery-hepatic duct flap was ready to be lifted. HA-HD: Hepatic artery-hepatic duct.

Figure 3

The hepatic artery-hepatic duct flap was lifted to show the portal vein, right portal vein, and left portal vein. RPV: Right portal vein; LPV: Left portal vein; MPV: Main portal vein; HA-HD: Hepatic artery-hepatic duct.

Figure 4

A simplified method to occlude the main portal vein while keeping hepatic artery blood flow. MPV: Main portal vein; HA: Hepatic artery.

Figure 5

A simplified method to occlude the main portal vein while keeping hepatic artery blood flow. HA: Hepatic artery; MPV: Main portal vein; CBD: Common bile duct.

Figure 6

Case 1. A: The computed tomography scan showed tumor thrombus in the right portal vein. B: Transcatheter arterial chemoembolization was performed before the operation. C: The thrombus was extracted from the right portal vein opening. PV: Portal vein; PVTT: Portal vein tumor thrombus.

Figure 7

Case 2. A: The computed tomography scan showed tumor thrombus in the right portal vein (RPV) and portal vein (PV). B: Transcatheter arterial chemoembolization was performed before the operation. C and D: The left portal vein (LPV), RPV and PV were clearly revealed by dissecting the hepatic artery-hepatic duct flap. E: The LPV and PV were taped. F: Tumor thrombus in the RPV and PV was extracted. G: The tumor thrombus in the LPV was extracted, and the RPV stump was closed. H: Live transection was performed by the anterior approach. PV: Portal vein; PVTT: Portal vein tumor thrombus; RPV: Right portal vein; LPV: Left portal vein; MPV: Main portal vein; HA-HD: Hepatic artery-hepatic duct.

Figure 8

Case 3. A: The computed tomography scan showed the left hepatocellular carcinoma (HCC) and tumor thrombus in the left portal vein (LPV) and portal vein (PV). B and C: 3D reconstruction of the left HCC. D: 3D reconstruction of tumor thrombus in the LPV and PV. PVTT: Portal vein tumor thrombus.