Newly found variations of the right posterior portal vein identified radiologically in 1,003 Chinese patients: a cross-sectional study.

Background: The anatomy of the right posterior portal vein (RPPV) plays an important role in planning hepatic resection, living transplantation and interventional radiological procedures, yet the incidence of variations of RPPV without a common trunk in Chinese persons is still unclear. Therefore, we conducted this study and discussed its clinical implications. Methods: A retrospective analysis of multidetector computed tomography (MDCT) scans was performed in 1,933 patients with various abdominal pathologies between September 28, 2018 through May 23, 2019. After excluding 930 patients, a total of 1,003 patients were included in this study. Variations of the RPPV without a common trunk were classified according to classification standards. Results: A total of 1,003 patients were included. RPPV without a common trunk was found in 216 (21.54%, 216/1,003) patients. Among them, we identified three variations of the origin from the right portal vein (RPV): first separate origin of P6, P7, or simultaneous separate origin of P6 and P7, and the incidences of these three variations were 1.50% (15/1,003), 6.58% (66/1,003) and 13.46% (135/1,003), respectively. Among 1,003 patients included in this study, 787 patients (78.46%, 787/1,003) showed that RPPV normally divided into P6 and P7 branches. Conclusions: Variations of the RPPV without a common trunk were not rare in Chinese population. Knowledge of this anatomic variation of the RPPV is extremely important for hepatic and transplant surgeons and interventional radiologists.

Isolated caudate lobe resection for huge hepatocellular carcinoma (10 cm or greater in diameter).

Isolated caudate lobectomy for huge hepatocellular carcinoma (HCC) (10 cm or greater in diameter) is a technically demanding surgical procedure that entails the surgeon's experience and precise anatomical knowledge of the liver. We describe our clinical experiences and evaluate the results of partial or total isolated caudate lobectomy for HCC larger than 10 cm in the caudate lobe. En bloc excisions combined with adjacent hepatic parenchyma (as part of extended hepatectomies) were excluded. Twenty-seven patients were included in the study (24 male, three3 female). Median age was 43 years (range, 18 to 81 years). All primary diagnoses were HCC. Twenty-one patients had surgical margins lesser than 1 cm. Tumor embolus within the main trunk of the portal vein was found in five patients by intraoperative ultrasound. Median operative time was 288 minutes (range, 160 to 310 minutes), and estimated intraoperative blood loss was 2260 mL (range, 200 to 7000 mL). Median blood transfusion was 1460 mL (range, 0 to 7200 mL). Postoperative morbidity rate was 44.4 per cent. There were no postoperative deaths. Overall survival rates at 1, 3, and 5 years were 80.2, 52.1, and 27.1 per cent, respectively. Nineteen patients (70.4%) had tumor recurrence as of the last follow-up. The recurrence lesion was treated in most of these patients. Isolated caudate lobectomy for huge HCC is a technically demanding but safe procedure, although the procedure is sometimes extremely difficult.

Null-margin bisegmentectomy VII-VIII for hepatocellular carcinoma in cirrhotic patients.

BACKGROUND/AIMS: Preservation of functional liver parenchyma should be a priority in hepatic surgery to avoid postoperative liver failure and enhance the opportunity to perform repeat resection in case of tumor recurrence. METHODOLOGY: A tumor localized in segments VII, VIII and adhering to or compressing the middle hepatic vein sometimes indicates a need to perform bisegmentectomy VII-VIII without surgical margin. From June 2006 to June 2011, fourteen patients with such a tumor underwent null-margin bisegmentectomy VII-VIII in our hospital. We retrospectively review our experience with this uncommon and technique-challenging hepatic resection. RESULTS: Mean intraoperative blood loss was estimated to be 300 mL and only four patients required blood transfusions less than 4U each person. Mean postoperative hospitalization was 11.2 days. Postoperative complications were encountered in 28.5% of patients and there was no postoperative mortality. Median overall and disease-free survivals were 35 and 23 months, respectively. CONCLUSIONS: The lack of ability to obtain an adequate surgical margin should not be considered as a contraindication for hepatectomy of HCC. In patients with impaired liver functional reserve and with right superiorly located tumors, the preservation of the middle hepatic vein should take priority and null-margin bisegmentectomy VII-VIII for HCC should be recommended.

Null-margin mesohepatectomy for centrally located hepatocellular carcinoma in cirrhotic patients.

BACKGROUND/AIMS: Anatomic mesohepatectomy is often anatomically restricted by the hilar structure and, therefore, difficult to perform with an adequate resection margin. Especially, in the case of a tumor which is in contact without infiltration with the critical intrahepatic vessels, mesohepatectomy has to be performed without a surgical margin. METHODOLOGY: From January 2005 to December 2009, thirty-seven patients with centrally located HCC underwent anatomic mesohepatectomy without resection margin in our hospital. The surgical techniques, clinicopathological characteristics and outcomes were reviewed. RESULTS: Mean operative time was 210 minutes (range 130 to 310 minutes) and mean intraoperative blood loss was 950 mL (range 150 to 4,500 mL). Mean postoperative hospitalization was 12.6 days (range 10 to 32 days). Postoperative complications were encountered in 37.8% of patients. The 1-, 3-, and 5-year recurrence-free survival rate was 75.1%, 39.3%, 22.5%, respectively, and the 1-, 3- and 5-year overall survival rate was 91.9%, 60.4%, 28.5%, respectively. CONCLUSION: Null-margin mesohepatectomy is an oncologically radical but parenchyma-sparing hepatic resection. In patients with impaired functional liver reserve and with centrally located tumors in contact without infiltration with major vessels, expected zero resection margins should not be considered as a contraindication for surgery, and null-margin mesohepatectomy should be recommended as a reasonable surgical option.

Anatomic resection of segment VIII of liver for hepatocellular carcinoma in cirrhotic patients based on an intrahepatic Glissonian approach.

BACKGROUND: Isolated segmentectomy VIII is a technically demanding operative procedure and is reported only rarely. To our knowledge, no reports on anatomic segmentectomy based on an intrahepatic approach have been described. For cirrhotic patients with hepatocellular carcinoma (HCC) limited to segment VIII, this is a parenchyma-preserving hepatectomy that can be tolerated. METHODS: Eighteen patients with HCC underwent anatomic segment VIII segmentectomy from January 2005 to January 2008 in our institution. The operative techniques, postoperative, and oncologic outcomes were reviewed. RESULTS: Anatomic segmentectomy VIII was feasible with the technology described herein in all patients. The perioperative and oncologic outcomes were comparable with those of other similar hepatic resections. The median follow-up time was 28 months. The 3-year survival rate was 65%. CONCLUSION: Although complex and technically demanding, an intrahepatic Glissonian approach for anatomic segmentectomy of segment VIII is an oncologically radical but parenchyma-sparing hepatic resection. In terms of preserving greater functioning liver parenchyma, it may be a safe and effective alternative to extensive hepatectomy.

Anatomic mesohepatectomy with extrahepatic control of hepatic veins.

BACKGROUND/AIMS: Intraoperative bleeding remains a major concern during mesohepatectomy because of doubled area of cut surface and proximity to important intrahepatic vascular structures. Preliminary extrahepatic exposure and looping of the main hepatic veins with the possibility of clamping them in association with total or partial vascular inflow occlusion, can lead to substantially reducing intraoperative bleeding. METHODOLOGY: From January 2003 to July 2008, preliminary exposure and looping of the main hepatic veins was performed in 67 patients undergoing mesohepatectomy. Among these patients, mesohepatectomy was performed with clamping of more than one of the main hepatic veins in 47 patients. We report the results obtained in those patients. RESULTS: Total vascular inflow occlusion with Pringle maneuver or partial vascular inflow occlusion based on an intrahepatic approach was used in all patients. The amount of intraoperative blood loss averaged (580 +/- 308) (range 180 to 4500) ml. No macroscopic tumor residue was encountered. There were no hospital deaths and the morbidity rate was 25.7%. The mean hospital stay was 11.2 days (range, 9-26). CONCLUSIONS: Our study showed that preliminary extrahepatic control of the main hepatic veins was a safe and technically feasible maneuver. During mesohepatectomy, clamping more than one of the main hepatic veins, in association with total or partial vascular inflow occlusion, is efficacious in reducing intraoperative bleeding.

Intrahepatic Glissonian access for mesohepatectomy in cirrhotic patients.

BACKGROUND/AIMS: For treatment of centrally located hepatocellular carcinoma (HCC), mesohepatectomy is a technically demanding procedure. The technique of an intrahepatic access to Glissonian pedicles achieves a safe inflow blood control of the liver segments to be resected and allows the anatomical removal of the tumor-bearing segment(s). No reports have mentioned the use of an intrahepatic access for mesohepatectomy in cirrhotic livers. METHODOLOGY: Seventeen consecutive patients underwent mesohepatectomy between January 1, 2005, and September 30, 2007. All these patients had hepatocellular carcinoma. The surgery was performed by making 3 small incisions around the hilar-plate, the gallbladder bed, and the round ligament. With a standardized method, the right anterior and left medial sheaths were reached by combining these incisions. RESULTS: Mesohepatectomy was feasible with the proposed technique in all patients. No patients experienced massive bleeding during the operation, and 14 patients did not require blood transfusion. Minor postoperative complications were observed in 8 patients and resolved with conservative management. No hospital mortality occurred. CONCLUSIONS: Intrahepatic Glissonian access for mesohepatectomy in cirrhotic patients is safe and effective. It may reduce intraoperative blood loss and the need for the Pringle maneuver.

Bisegmentectomy VII-VIII for hepatocellular carcinoma in cirrhotic livers.

BACKGROUND/AIMS: Preservation of nontumorous liver parenchyma should be a priority in hepatic surgery in order to avoid the risk of life-threatening liver failure and maximize the possibility of repeat resection. METHODOLOGY: A tumor localized in segments VII, VIII and infiltrating the main trunk of the superior right hepatic vein usually indicates a need to perform a right hepatectomy. With the presence of a stout inferior right hepatic vein, bisegmentectomy VII, VIII can be carried out without the risk of hepatic congestion in the remaining segment VI. We retrospectively review our experience with this rare and challenging hepatic resection. RESULTS: In 23 of 715 patients with primary hepatocellular carcinoma, the tumor was localized in segments VII, VIII and involved with the superior right hepatic vein. Eleven underwent bisegmentectomy VII, VIII. Mean operative blood loss was estimated to be 300mL (200-1200mL), and only three patients required blood transfusions less than 2U each person. No patient had postoperative life-threatening liver failure and there was no postoperative mortality. All resection margins were negative. Median overall and disease-free survivals were 31 and 11 months, respectively, with five patients alive and disease-free. CONCLUSIONS: Bisegmentectomy VII and VIII is an oncologically radical but parenchyma-preserving liver resection. Though a rare hepatic resection, it can be performed safely with low morbidity and mortality in selected patients.

[Highly-selective regional vascular exclusion for large liver tumor resection].

OBJECTIVE: To evaluate the highly-selective regional vascular exclusion in the risk hepatectomy for liver tumor. METHODS: Short hepatic veins were ligated and divided followed by the dissection, and isolation of the inflow and outflow vessels of the tumor-bearing lobe, which were completely devascularized after the occlusion of these vessels. The blood loss volume, postoperative recovering situation of the liver function and the incidence of complication were observed in 68 cases. RESULTS: Main hepatic veins were dissected and isolated exo-hepatically in 65 cases. In the other 3 cases, the main hepatic veins were blocked by Satin skin clamp applied longitudely along the inferior vena cava. Hepatic pedicle was routinely excluded.The amount of blood loss was from 400 to 1200 (600+/-200) mL and 26 (65%) cases didn't receive transfusion.There was no operative mortality and liver function failure. Surgical complications included subphrenic abscess in 2 cases and bile leakage in 2 cases, which were cured conservatively. CONCLUSION: Highly-selective regional exclusion of hepatic blood flow during the risk hepatectomy is safe and effective to prevent massive bleeding and to reduce the incidence of liver failure.

Surgical treatment of primary duodenal adenocarcinoma.

BACKGROUND/AIMS: Our purpose was to review the outcome of the patients with primary duodenal adenocarcinoma and determine factors influencing survival. METHODOLOGY: Over a 10-year period, 43 patients with this disease were identified. Data were analyzed to assess the outcomes of treatment and predictors of survival. RESULTS: Patients had symptoms present for an average of 6 months. The most common symptom was obstructive jaundice, observed in 55.8% of the cases. Based on symptomology, primary duodenal adenocarcinoma may be classified into three categories: icteric, obstructive and illusive. The upper gastrointestinal contrast study and esophagogastroduodenoscopy were the most effective diagnostic tests, showing an accuracy of 79.5% and 86.8%, respectively. A curative resection was performed in 28 of the 43 patients (65.1%), a conventional pancreatoduodenectomy in 11, segmental duodenal resection in 16 and gastroduodenectomy in 1. The overall 5-year survival rate was 27%, which was 42 percent after curative resection. CONCLUSIONS: The respectability of the primary lesion was associated with increased survival. An aggressive surgical approach should be pursued. Pancreaticoduodenectomy is usually required for tumors of the first and second portion of the duodenum. Segmental resection may be appropriate for selected patients, especially for cancers of the distal duodenum.

Anterior approach for complete isolated caudate lobectomy.

BACKGROUND/AIMS: Complete isolated caudate lobectomy is a technique-demanding procedure that entails the surgeon's judgement and precise knowledge of liver anatomy. METHODOLOGY: All consecutive patients who underwent complete isolated caudate lobectomy were studied. En bloc excisions combined with adjacent hepatic parenchyma (as part of extended hepatectomies) or wedge excisions of the caudate lobe were excluded. All patients were followed-up to date. RESULTS: Thirteen patients met the inclusion criteria (9 male, 4 female). Mean age (+/-SD) was 47 (+/-9) years. Primary diagnoses included hepatocellular carcinoma, hemangioma and adenoma. Margins were negative in all but two patients. Intraoperative US showed no tumor embolus within the main hepatic veins. Mean (+/-SD) operative time was 245 (+/-45) minutes, and estimated blood loss was 680 (+/-210) mL. Median blood transfusion was 420mL (range, 0 approximately 2500mL). Complications included bile leak in one patient, ascites in 2. Median length of hospitalization was 13 days (range, 11-21). There was no perioperative mortality. CONCLUSIONS: Complete isolated resection of the caudate lobe using the anterior approach should be the first choice for treatment of a tumor located in the caudate lobe alone, although the procedure is extremely difficult and highly dangerous.