Isidoro Di Carlo

Catania, Italy

Liver tumors invading the hepatocaval confiuence: treatment improvements still not completed

Isidoro Di Carlo

Catania, Italy

Also if rarely, hepatocellular carcinoma, cholangiocarcinoma, and metastatic carcinoma can invade the retrohepatic portion of the inferior vena cava (IVC), because of the proximity of this vessel to the liver.[1]

Innovative vascular exclusion techniques and new surgical resection methods, derived from improvements in liver surgery and transplantation, have allowed us to treat many tumors that have long been considered inoperable.[1]Many previously prohibitive operations have been made possible by combination of total vascular exclusion,[2]venovenous bypass,[2]clamping the IVC below the hepatic vein, or two-step vascular exclusion[3]with in vivo, in situ, ante-situm or ex vivo hepatectomy.[4]

Tumors that extend into the IVC are usually located in the posterior or superior segments of the liver. When tumor invasion of the IVC is ＜2 cm, usually the operation can be done by tangentially placing a vascular clamp on the IVC.[3]A simple lateral venorrhaphy can complete the procedure. This approach must be planified before surgery, as the IVC can become narrow after suturing.[3]Azoulay et al[3]proposed suturing the IVC wall transversely to avoid stenosis. When infiltration of the IVC is＞2 cm and ＜50% of the circumference, a patch can be used to repair the defect after IVC wall excision.[5]Autologous saphenous vein, fascial peritoneum, or bovine pericardium can be used to repair the defect. When the wall of the IVC is invaded ＞50%, or in case of longitudinal infiltration, usually an expanded polytetrafluoroethylene (ePTFE) tube graft (Gore-Tex?), or other graft are needed to replace the entire IVC.[5]

When extensive resection is needed and simple clamping of the IVC does not achieve a satisfactory result, many techniques can be used. In situ hypothermic perfusion and the ante-situm technique are the most frequently used. Ex vivo resection is usually reserved for situations with massive involvement of the IVC and hepatic veins that cannot be treated with other techniques.[1]

In the present issue, Li and colleagues[5]report on their experience with 42 consecutive patients who underwent hepatectomy, combined with IVC replacement and/or hepatic vein reconstruction for hepatocellular carcinoma. The patients were divided into three groups based on the surgical approach for hepatic vein reconstruction: group 1, tumor invaded the hepatocaval confluence but one or two hepatic veins were not involved in the residual liver, and it was not necessary to reconstruct the hepatic outflow; group 2, tumor invasion extended to the hepatocaval confluence of the residual liver, and the hepatic vein defect was repaired with ePTFE or autogenous vein patches; and group 3, tumor extended to the hepatocaval confluence of the residual liver, and the hepatic vein had to be reconstructed with an artificial blood vessel to replace the IVC.

All of the techniques are described adequately and the authors have added details of their previous experience from the literature, confirming some issues, but leaving open some still unresolved problems. One of the unresolved issues is which type of material is best for vessel reconstruction. The authors encountered a small amount of infection in the postoperative period that was cured with antibiotics. The main cause of this infection was the bile coming from the resected surface. This complication is described in other reports in the literature.[1]

This issue needs to be investigated, as no randomized study has established which are the best materials for vessel reconstruction, especially in cases of infection. The authors used anticoagulants for all of the patients, but there was no certainty in the literature about their use.[1,3]

Finally, the authors reported that four patients died from liver failure. All three groups included patients who were Child-Pugh B cirrhosis. Such patients have a strict indication for surgery, especially if extensive surgery is required. Patients with Child-Pugh A cirrhosis depending on their indocyanine green clearance rate at 15 minutes, cannot be submitted to extensive hepatectomy. This complication has been reported in other studies and is probably another issue to be resolved. The Makuuchi algorithm can be useful in hepatocellular carcinoma or in patients previously subjected to chemotherapy.[6,7]This is a challenging procedure with associated mortality, and defining the indications can help to better stratify the patients and restrict the procedure to selected patients who may have acceptable survival with good quality of life.

Contributors: DCI wrote the whole manuscript.

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.

1 Hemming AW, Mekeel KL, Zendejas I, Kim RD, Sicklick JK, Reed AI. Resection of the liver and inferior vena cava for hepatic malignancy. J Am Coll Surg 2013;217:115-125.

2 Huguet C, Addario-Chieco P, Gavelli A, Arrigo E, Harb J, Clement RR. Technique of hepatic vascular exclusion for extensive liver resection. Am J Surg 1992;163:602-605.

3 Azoulay D, Andreani P, Maggi U, Salloum C, Perdigao F, Sebagh M, et al. Combined liver resection and reconstruction of the supra-renal vena cava: the Paul Brousse experience. Ann Surg 2006;244:80-88.

4 Oldhafer KJ, Lang H, Schlitt HJ, Hauss J, Raab R, Klempnauer J, et al. Long-term experience after ex situ liver surgery. Surgery 2000;127:520-527.

5 Li W, Wu H, Han J. Surgical outcomes of hepatocellular carcinoma invading hepatocaval confluence. Hepatobiliary Pancreat Dis Int 2016;15:593-601.

6 Torzilli G, Makuuchi M, Inoue K, Takayama T, Sakamoto Y, Sugawara Y, et al. No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach. Arch Surg 1999;134:984-992.

7 Elias D, Lasser P, Rougier P, Ducreux M, Bognel C, Roche A. Frequency, technical aspects, results, and indications of major hepatectomy after prolonged intra-arterial hepatic chemotherapy for initially unresectable hepatic tumors. J Am Coll Surg 1995;180:213-219.

Received October 6, 2016

Accepted after revision October 17, 2016

Author Affiliations: Department of Surgical Sciences and Advanced Technologies, University of Catania, Catania, Italy (Di Carlo I)

Isidoro Di Carlo, MD, PhD, FACS, FBSS (Hon.), Professor of Surgery (ASN 2012), Department of Surgical Sciences and Advanced Technologies, University of Catania, Cannizzaro Hospital, Via Messina 829, 95126 Catania, Italy (Tel: +39-095-7264863; Fax: +39-095-7263020; Email: idicarlo@unict.it)

? 2016, Hepatobiliary Pancreat Dis Int. All rights reserved.

10.1016/S1499-3872(16)60153-4

Published online November 4, 2016.