Inevitable Anterior Approach for a Massive Hepatoma with Diaphragmatic Invasion

PURPOSE: Most liver surgeons perform a right hepatic resection for a hepatocellular carcinoma (HCC) for the complete mobilization of the right lobe of liver, via the conventional approach, prior to a parenchymal transection. However, in selected patients, with a massive hepatoma that has invaded to the diaphragm, the conventional mobilization of the liver prior to a parenchymal transection may be very difficult and result in excessive bleeding. The feasibility of an 'anterior approach' was evaluated by analyzing of the clinical result of the surgical treatment for a massive hepatoma with diaphragmatic invasion. METHODS: Between November, 2001 and November, 2002, six patients underwent a major right hepatic resection, using an anterior approach, for a HCC that had invaded or was adhered to the diaphragm, preventing the easy mobilization of the right lobe of the liver. RESULTS: There was no hospital mortality among six patients. A massive transfusion, followed by massive bleeding, was performed in four patients, but no post-operative liver failure occurred. CONCLUSION: These cases, performed via an anterior approach, had massive bleeding, but no hospital mortality or post- operative liver failure was observed. If the patients had undergone the procedure via the conventional approach, much more bleeding would have been expected. An 'anterior approach' is a safe and effective option in selected patients with a massive hepatoma and diaphragmatic invasion.

Outcomes of Hepatic Resection Using Intermittent Hepatic Vascular Inflow Occlusion with Low Central Venous Pressure / 한국간담췌외과학회지

PURPOSE: Blood loss and transfusions during a liver resection are associated with higher morbidity and mortality rates. With applying hepatic vascular inflow occlusion (Pringle maneuver), persistent bleeding during a hepatic transection is caused by back flow from the hepatic veins. Therefore, low central venous pressure facilitates to reduce-bleeding from the hepatic veins by lowering the back flow pressure gradient. An intermittent hepatic vascular inflow occlusion was applied, with a lowering of the central venous pressure, during a hepatic resection in our series of patient. The effect of these maneuvers in reducing bleeding and the postoperative complication rates were analyzed. METHODS: Between December 2000 and September 2003, in 153 hepatic resection patients, where this technique was used, the intermittent vascular inflow occlusion and maintenance of the central venous pressure as low as possible were accrued in this study. The overall outcomes of patients that had a hepatic resection, focusing on the amount of bleeding, blood product transfusion and complication rates, were analyzed. RESULTS: The median blood loss was 652.5 ml, and 111 patients (72.5%) required no perioperative blood transfusion. The median units of blood required in the patients who needed a transfusion were 2.3 U. There was no evidence of renal derangement related with low blood flow into the kidney by keeping central venous pressure as low as possible. There were minor complications in 34 patients (22.4%) and two in-hospital mortalities (1.3%) associated with hepatic failure in cirrhotics. CONCLUSION: A hepatic resection, with an intermittent Pringle maneuver and a low central venous pressure, is a very simple and effective modality to reduce bleeding during a hepatic transection, with low morbidity and mortality rates and without hepatic and renal dysfunctions.

Application of selective hepatopetal blood flow occlusion for anatomic hepatectomy / 中国普通外科杂志

Objective To investigate the application of selective hepatopetal blood occlusion techniques in anatomic hepatectomy.Methods We retrospectively reviewed the clinical data of 259 patients with hepatolithiasis or liver tumor undergoing anatomic hepatectomy under selective hepatopetal blood occlusion from January 2006 to December 2009.Results Totally,183 cases with hepatolithiasis and 76 cases with liver tumor underwent anatomic hepatectomy under selective hepatopetal blood occlusion.The average intra-operation blood loss was 210 mL(120-1 600 mL);post-operation incidence of complications and the rate of residual stones was 10.9% and 4.2%,respectively.Thre was no operative death in this series.The intrahepatic recurrence and metastasis rate of liver tumor was 23.6% and the median recurrence was 16.3 months.Conclusions The use of a appropriate selective hepatopetal blood occlusion during anatomic hepatectomy for hepatolithiasis and liver tumors is an effective measure to reduce surgical complications and improve outcome.

Selective hemihepatic vascular occlusion in hepatectomy for large hepatocellular carcinomas / 中国普通外科杂志

Objective To evaluate the clinical values of selective hemihepatic vascular occlusion in hepatectomy for large hepatocellular carcinomas.Methods Forty patients with large hepatocellular carcinomas who underwent hepatectomy with selective hepatic inflow and outflow occlusion of tumor-bearing liver were retrospectively analyzed.Results All the 40 patients underwent hepatectomy successfully.The blood losts during the operation was 100-800 mL(average 360 mL).The operation time was 90-150 min(average 116 min).Intraoperative blood transfusion was not performed in twenty-five patients.All patients recovered completely and were discharged without liver function failure or other severe complications.There was no perioperative death.Conclusions Selective hemihepatic vascular occlusion in hepatectomy for large hepatocellular carcinomas is a safe and effective method with advantages of controlling hemorrhage,decreasing liver damage and gut barrier injury,avoiding air embolism and preventing metastasis.

A comparative study of hand-assisted laparoscopic versus open hepatectomy for liver cancer / 中国普通外科杂志

Objective To study the feasibility and invasiveness of hand-assisted laparoscopic hepatectomy(HALH) for liver cancer.Methods Forty patients undergoing hepatectomy for liver cancer were randomly divided into HALH group and open hepatectomy(OH) group.Data of patients of two groups,Which included operating time,intraoperative blood loss,length of incision,postoperative flatus time,hospital stay,complications and C-reactive protein(CRP) were compared.Results The mean intraoperative blood loss,length of incision,postoperative flatus time,hospital stay and CRP in HALH group were significantly less than that in OH group;but there was no significant difference in operating time,or complication and recurrence rate.Conclusions HALH for liver cancer is less traumatic,and achieves faster patient recovery.It is feasible and safe in selected patients.

Clinical study on hepatic segmentectomy under segmental staining and intraoperative chemoembolization for primary liver cancer / 中国普通外科杂志

Objective To explore the clinical efficacy of hepatic segmentectomy under segmental staining and intraoperative chemoembolization for primary liver cancer(PLC).Methods Twenty cases of liver cancer underwent hepatic segmentectomy under segmental staining and intraoperative chemoembolization(observed group),the results were compared with 22 cases of PLC after treated by routine hepatectomy(control group).AFP,CT and MRI were regularly used after hepatectomy to evaluate the outcome.Results In observed group,the operative blood loss was(295?105)mL,blood transfusion was(280?85)mL,liver function levels were in the normal range accounted for 15%(3/20) one week postoperatively,the incidence of postoperative complications was 40%(8/20),the postoperative 3-year survival rate was 60%,and the postoperative local recurrence rate was 35%;while in the control group,these parameters were(490?140)mL,(370?105)mL,40.9%(9/22),45.5%(10/22),40.91% and 68.18% respectively.In observed group,the operative blood loss,blood transfusion,cases with liver function levels in the normal range,the incidence of postoperative complications,postoperative 3-year survival rate,and postoperative local recurrence rate were significantly lower than those in the control group(P0.05).Conclusions The hepatic segmentectomy under segmental staining and intraoperative chemoembolization for PLC may reduce postoperative complications,lower postoperative relapse rate and improve survival rate.

Caudate lobectomy for liver cancer in candafe lobe:a report of 11 cases / 中国普通外科杂志

Objective To explore the safe technique of caudate lobectomy for liver cancer in candafe lobe(LCCL).Methods The clinical data of 11 cases of primary liver cancer in caudate lobe who received hepatectomy successfully were retrospectively analyzed. four procedures were used in the operations:(1)selection of appropriate skin incision, so as to obtain excellent exposure of operative field;(2)adequate mobilization of the liver to allow the liver to be displaced upwards to the left or to the right;(3)preparatory placement of tapes for total hepatic vascular isolation,so that this procedure can be used when necessary;(4)selection of the ideal route for hepatectomy based on the condition of the tumor and, if necessary, the combined removal of multiple lobes. Among the 11 cases, simple occlusion of vessels of porta hepatis was used for candate lobectomy in 6 cases, while, in the other cases, the vessels were intermittently occluded several times or total hepatic vlascular isolation was used for the caudate lobectomy. combined partial right hepatectomy was done in 2 cases, combined left lateral lobectomy in 3 cases and caudate lobectomy alone in 6 cases.Results Operation was smooth and successful in all of the 11 cases, and there was no mortality. Conclusions Caudate lobectomy for LCCL can be safely performed when the above procedures are used.

Hepatectomy in the treatment of hepatolithiasis: a report of 316 cases / 中国普通外科杂志

Objective To summarze our experience and evaluate the therapeutic effect of hepatectomy for intrahepatic bile duct stones. Methods The clinical data of 316 patients suffering from intrahepatic lithiasis who underwent hepatectomy from Feb. 1985 to Dec. 2004 were retrospectively analyzed. Stones distribution, operation modality, postoperative complications, and therapeutic effect were evaluated. Among the 316 patients, 192 cases(60.76%) were treated with left lateral hepatectomy, 58 cases(18.35%) with left hemihepatectomy, 12 cases(3.80%)with quadarate lobectomy, 54 cases(17.09%) with right hemihepatectomy or segmentectomy, and 14 cases(4.43%)with left and right segmentectomy. Additional biliary procedures including common bile duct exporation and cholangio-enterostomy were performed in 184 patients(58.23%). Results Postoperative complications occurred in 56(17.72%)cases, including biliary fistula, hemobilia, and subdiaphragmatic infections. Three patients(0.95%)died. The follow-up study conducted in 258 patients(81.65%)for an average of 10.3 years showed that excellent results were achieved in 90.31% of the patients. Conclusions Regular hepatic lobectomy/segmentectomy is the most effective treatment for intrahepatic lithiasis.