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Hepatic bisegmentectomy 7–8 for a colorectal metastasis
EJSO 32 (2006) 469–471
www.ejso.com
Lesson of the Month
Hepatic bisegmentectomy 7–8 for a colorectal metastasis L. Capussotti*, A. Ferrero, L. Vigano`, R. Polastri, D. Ribero, E. Berrino Unit of Surgical Oncology, Institute for Cancer Research and Treatment, Strada Provinciale 142, km 3,95, 10060 Candiolo, Italy Accepted 13 January 2006 Available online 7 March 2006
Keywords: Liver surgery; Intraoperative color-Doppler ultrasonography; Colorectal liver metastases; Bisegmentectomy 7–8; Inferior right hepatic vein
Introduction A parenchymal sparing strategy should be always considered during liver resection in order to avoid postoperative liver failure and to allow a future reresection.1,2 A right hepatectomy is usually required for tumours infiltrating the right hepatic vein (RHV) close to its confluence with the vena cava. Makuuchi (1987)3 reported the first resection of segments 7 and 8, sparing segments 5 and 6, but with the presence of a large inferior right hepatic vein (IRHV).4–11 This report describes the first bisegmentectomy of segments 7 and 8 in the absence of an IRHV. Case report A 71-year-old man presented with extraperitoneal rectal adenocarcinoma and a single synchronous liver metastasis in segments 2–3. He underwent an anterior resection associated with synchronous bisegmentectomy Sg2–3, three cycles of adjuvant chemotherapy with 5-fluorouracil and external pelvic radiotherapy (50 Gy). Six months later, abdominal CT scan revealed a 5 cm liver metastasis in Sg7–8 close to the RHV. Pre-operative abdominal MRI confirmed the metastasis (Fig. 1) and reported a second small lesion in Sg1. He was scheduled for two wedge liver resections preserving the RHV. An extended right subcostal laparotomy was performed; intraoperative ultrasonography (IOUS) showed a mass in Sg7 and Sg8 infiltrating the RHV 3 cm from its confluence with the vena cava; the small lesion of Sg1 was confirmed. The RHV required ligation in order to * Corresponding author. Tel.: C39 011 9933449; fax: C39 011 9933440. E-mail address: [email protected] (L. Capussotti).
0748-7983/$ - see front matter q 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2006.01.004
obtain a radical resection. An IRHV was not detected by pre-operative examinations, and IOUS confirmed its absence. The right liver was completely mobilized and no retrohepatic vein was encountered: the anterior surface of vena cava was completely exposed without any vein ligation or coagulation. Sg5–6 congestion was evaluated by color-Doppler IOUS of the portal inflow after RHV isolation and clamping: the flow in the right posterior portal branch decreased (16 vs 11 cm/s) but remained hepatopetal (Fig. 2). After right hepatic artery occlusion, no discoloration appeared on the liver surface. Therefore, the RHV was ligated and a bisegmentectomy Sg7–8 was performed without pedicle clamping (Fig. 3). A wedge resection of Sg1 was performed. Post-operative course was uneventful and the patient was discharged on post-operative day 11. Abdominal CT scan 1 month after hepatectomy showed neither congestion nor atrophy of Sg6 parenchyma. Discussion Liver resection is the only curative treatment for patients with colorectal liver metastases.12 Recent studies have reported usefulness of parenchymal sparing surgery in order to leave an adequate remnant liver and reduce postoperative liver failure, mainly in patients with liver steatosis or cirrhosis.1,2,13 Moreover, a parenchymal sparing strategy can allow the surgical treatment of some hepatic recurrence by reresection.12 Technical issues In the past, right hepatectomy was considered the only resection possible for tumours sited in Sg7–8
470
L. Capussotti et al. / EJSO 32 (2006) 469–471
Figure 1. Pre-operative abdominal MRI showing a 5 cm liver metastasis in Sg7–8 close to the RHV, but not infiltrating it.
and infiltrating the RHV. Segment 6 and the lateral portion of Sg5 were supposed to be drained exclusively by branches of the RHV. RHV ligation would have lead to venous congestion. However, since 1970 many studies described the presence of an IRHV selectively draining the right postero-inferior segment.4,5 An IRHV is present in almost all patients (86–100%),4,7 but it is larger than 0.5 cm in only about 10–28% of cases.4–9 Pre-operative ultrasonography, multislice abdominal CT scan and MRI can identify an IRHV and its presence is intraoperatively confirmed by IOUS. 10,11 Considering this venous drainage, in 1987 Makuuchi reported a bisegmentectomy Sg7–8 ligating the RHV and preserving Sg6 and Sg5, without any congestion of these segments.3 This type of resection is technically demanding and rarely reported, representing less than 1% of all the hepatic resections.2,3,14 In our series of more than 800 liver resections, we performed only six bisegmentectomies Sg7–8 without in-hospital mortality and liver failure.15 To our knowledge bisegmentectomy Sg7–8 without an IRHV has never been reported, because of the risk of Sg6 venous congestion.
Anatomic considerations Couinaud’s studies described hepatic venous anastomoses in 25 of 30 examined casts and their presence was demonstrated in Budd–Chiari syndrome.5,16 Two more studies reported venous anastomoses between the middle hepatic vein (MHV) and the RHV in half of the examined cases.17,18 Moreover, Masselot described a tributary of the MHV draining Sg6 running through Sg5 in 12% of 80 examined casts and Sano identified this branch with IOUS in about 13% of patients.4,19 Even though these anastomoses are described, it is unclear whether they would drain Sg6 completely after RHV occlusion.18 Color-Doppler evaluation Parenchymal venous congestion has been debated for reconstruction of the middle hepatic vein tributaries of the liver graft in living donor liver transplantation (LDLT) when the MHV is separated from the graft; in such a case there is the risk of congestion of the right paramedian sector (Sg5–8).19 Sano performed color-Doppler IOUS to check
Figure 2. Color-Doppler IOUS of the portal inflow in the right posterior portal branch before (a) and after (b) RHV clamping: the flow decreased (16 vs 11 cm/s) but remained hepatopetal.
L. Capussotti et al. / EJSO 32 (2006) 469–471
471
is mandatory to evaluate the vascular pattern of the remaining Sg6.
References
Figure 3. Bisegmentectomy Sg7–8: (a) liver surface without any discoloration after right hepatic artery occlusion; (b) raw cut surface at the end of parenchymal transection with ligated RHV.
hepatic venous and portal flow in the occlusive area after MHV clamping: in the presence of patent venous anastomoses, portal flow remained hepatopetal in Sg5–8 and hepatic venous flow in MHV was regurgitated in tributaries toward the RHV through anatomoses. On the other hand, if anastomoses did not work, portal flow became hepatofugal in the veno-occlusive area. Hepatic artery clamping confirmed color-Doppler IOUS results: if Sg5–8 were not drained by the RHV the congested area showed a discoloration on the liver surface during arterial clamping.19 We employed the same technique in our patient. After RHV clamping, color-Doppler IOUS showed that portal flow in Sg6 remained hepatopetal, even in presence of an inverted flow in the RHV; no ischemic discoloration on liver surface occurred after right hepatic artery occlusion. The information obtained from IOUS allowed us to perform a bisegmentectomy Sg7–8 with ligation of the RHV without any congestion of the remaining Sg6. This was possible thanks to the patency of anastomotic branches between the right and the middle hepatic veins. Parenchymal preservation in the face of venous congestion is still debated: Kaneko et al. reported that venous anastomoses can become patent and detectable by Doppler ultrasonography only 6 days after LDLT,20 but Sano reported relieved congestion in only 43% of patients.19 Intraoperative evidence of hepatofugal flow in portal branches for Sg6 after RHV occlusion or Sg6 discoloration after artery clamping should be considered a contraindication to Sg6 sparing. In conclusion, bisegmentectomy Sg7–8 in the absence of an IRHV is feasible; IOUS with color-Doppler study
1. Hemming AW, Reed AI, Howard RJ, Fujita S, Hochwald SN, Caridi JG, et al. Preoperative portal vein embolization for extended hepatectomy. Ann Surg 2003;237(5):686–91. 2. Chouillard E, Cherqui D, Tayar C, Brunetti F, Fagniez PL. Anatomical bi- and trisegmentectomies as alternatives to extensive liver resections. Ann Surg 2003;238(1):29–34. 3. Makuuchi M, Hasegawa H, Yamazaki S, Takayasu K. Four new hepatectomy procedures for resection of the right hepatic vein and preservation of the inferior right hepatic vein. Surg Gynecol Obstet 1987;164(1):68–72. 4. Masselot R, Leborgne J. E´tude anatomique des ve`ines sus-he`patiques. Anat Clin 1978;1:109–25. 5. Couinaud C. Le foie. E`tudes anatomiques et chirurgicales. Paris: Masson; 1957. 6. Chevallier JM. Anatomic basis of vascular exclusion of the liver. Surg Radiol Anat 1988;10:187–94. 7. Nakamura S, Tsuzuki T. Surgical anatomy of the hepatic veins and the inferior vena cava. Surg Gynecol Obstet 1981;152:43–50. 8. Champetier J, Haouari H, Le Bas JF, Letoublon C, Alnaasan I, Farah I. Large inferior right hepatic vein. Clinical implications. Surg Radiol Anat 1993;15(1):21–9. 9. De Cecchis L, Hribernik M, Ravnik D, Gadzijev EM. Anatomical variations in the pattern of the right hepatic veins: possibilities for type classification. J Anat 2000;197(Pt 3):487–93. 10. Makuuchi M, Hasegawa H, Yamazaki S, Bandai Y, Watanabe G, Ito T. The inferior right hepatic vein: ultrasonic demonstration. Radiology 1983;148(1):213–7. 11. Cheng YF, Huang TL, Chen CL, Chen TY, Huang CC, Ko SF, et al. Variations of the middle and inferior right hepatic vein: application in hepatectomy. J Clin Ultrasound 1997;25(4):175–82. 12. Adam R, Pascal G, Azoulay D, Tanaka K, Castaing D, Bismuth H. Liver resection for colorectal metastases: the third hepatectomy. Ann Surg 2003;238(6):871–83 [discussion 883–4]. 13. Farges O, Belghiti J, Kianmanesh R, Regimbeau JM, Santoro R, Vilgrain V, et al. Portal vein embolization before right hepatectomy: prospective clinical trial. Ann Surg 2003;237(2):208–17. 14. Hamy A, d’Alincourt A, Floch I, Madoz A, Paineau J, Lerat F. Bisegmentectomy 7–8: importance of preoperative diagnosis of a right inferior hepatic vein. Ann Chir 2004;129(5):282–5. 15. Muratore A, Conti P, Amisano M, Bouzari H, Capussotti L. Bisegmentectomy 7–8 as alternative to more extensive liver resections. J Am Coll Surg 2005;200(2):224–8. 16. Maguire R, Doppman JL. Angiographic abonrmalities in partial Budd– Chiari syndrome. Radiology 1977;122:629–35. 17. Lasinski W, Zientarski B. The anastomotic system of sub-hepatic veins in man. Bull Assoc Anat (Nancy) 1976;60(170):559–66. 18. Hribernik M, de Cecchis L, Trotovsek B, Gadzijev EM, Ravnik D. Anatomical variations of the right hepatic veins and their relevance to surgery. Hepatogastroenterology 2003;50(51):656–60. 19. Sano K, Makuuchi M, Miki K, Maema A, Sugawara Y, Imamura H, et al. Evaluation of hepatic venous congestion: proposed indication criteria for hepatic vein reconstruction. Ann Surg 2002;236(2):241–7. 20. Kaneko T, Kaneko K, Sugimoto H, Inoue S, Hatsuno T, Sawada K, et al. Intrahepatic anastomosis formation between the hepatic veins in the graft liver of the living related liver transplantation: observation by Doppler ultrasonography. Transplantation 2000;70(6):982–5.
www.ejso.com
Lesson of the Month
Hepatic bisegmentectomy 7–8 for a colorectal metastasis L. Capussotti*, A. Ferrero, L. Vigano`, R. Polastri, D. Ribero, E. Berrino Unit of Surgical Oncology, Institute for Cancer Research and Treatment, Strada Provinciale 142, km 3,95, 10060 Candiolo, Italy Accepted 13 January 2006 Available online 7 March 2006
Keywords: Liver surgery; Intraoperative color-Doppler ultrasonography; Colorectal liver metastases; Bisegmentectomy 7–8; Inferior right hepatic vein
Introduction A parenchymal sparing strategy should be always considered during liver resection in order to avoid postoperative liver failure and to allow a future reresection.1,2 A right hepatectomy is usually required for tumours infiltrating the right hepatic vein (RHV) close to its confluence with the vena cava. Makuuchi (1987)3 reported the first resection of segments 7 and 8, sparing segments 5 and 6, but with the presence of a large inferior right hepatic vein (IRHV).4–11 This report describes the first bisegmentectomy of segments 7 and 8 in the absence of an IRHV. Case report A 71-year-old man presented with extraperitoneal rectal adenocarcinoma and a single synchronous liver metastasis in segments 2–3. He underwent an anterior resection associated with synchronous bisegmentectomy Sg2–3, three cycles of adjuvant chemotherapy with 5-fluorouracil and external pelvic radiotherapy (50 Gy). Six months later, abdominal CT scan revealed a 5 cm liver metastasis in Sg7–8 close to the RHV. Pre-operative abdominal MRI confirmed the metastasis (Fig. 1) and reported a second small lesion in Sg1. He was scheduled for two wedge liver resections preserving the RHV. An extended right subcostal laparotomy was performed; intraoperative ultrasonography (IOUS) showed a mass in Sg7 and Sg8 infiltrating the RHV 3 cm from its confluence with the vena cava; the small lesion of Sg1 was confirmed. The RHV required ligation in order to * Corresponding author. Tel.: C39 011 9933449; fax: C39 011 9933440. E-mail address: [email protected] (L. Capussotti).
0748-7983/$ - see front matter q 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2006.01.004
obtain a radical resection. An IRHV was not detected by pre-operative examinations, and IOUS confirmed its absence. The right liver was completely mobilized and no retrohepatic vein was encountered: the anterior surface of vena cava was completely exposed without any vein ligation or coagulation. Sg5–6 congestion was evaluated by color-Doppler IOUS of the portal inflow after RHV isolation and clamping: the flow in the right posterior portal branch decreased (16 vs 11 cm/s) but remained hepatopetal (Fig. 2). After right hepatic artery occlusion, no discoloration appeared on the liver surface. Therefore, the RHV was ligated and a bisegmentectomy Sg7–8 was performed without pedicle clamping (Fig. 3). A wedge resection of Sg1 was performed. Post-operative course was uneventful and the patient was discharged on post-operative day 11. Abdominal CT scan 1 month after hepatectomy showed neither congestion nor atrophy of Sg6 parenchyma. Discussion Liver resection is the only curative treatment for patients with colorectal liver metastases.12 Recent studies have reported usefulness of parenchymal sparing surgery in order to leave an adequate remnant liver and reduce postoperative liver failure, mainly in patients with liver steatosis or cirrhosis.1,2,13 Moreover, a parenchymal sparing strategy can allow the surgical treatment of some hepatic recurrence by reresection.12 Technical issues In the past, right hepatectomy was considered the only resection possible for tumours sited in Sg7–8
470
L. Capussotti et al. / EJSO 32 (2006) 469–471
Figure 1. Pre-operative abdominal MRI showing a 5 cm liver metastasis in Sg7–8 close to the RHV, but not infiltrating it.
and infiltrating the RHV. Segment 6 and the lateral portion of Sg5 were supposed to be drained exclusively by branches of the RHV. RHV ligation would have lead to venous congestion. However, since 1970 many studies described the presence of an IRHV selectively draining the right postero-inferior segment.4,5 An IRHV is present in almost all patients (86–100%),4,7 but it is larger than 0.5 cm in only about 10–28% of cases.4–9 Pre-operative ultrasonography, multislice abdominal CT scan and MRI can identify an IRHV and its presence is intraoperatively confirmed by IOUS. 10,11 Considering this venous drainage, in 1987 Makuuchi reported a bisegmentectomy Sg7–8 ligating the RHV and preserving Sg6 and Sg5, without any congestion of these segments.3 This type of resection is technically demanding and rarely reported, representing less than 1% of all the hepatic resections.2,3,14 In our series of more than 800 liver resections, we performed only six bisegmentectomies Sg7–8 without in-hospital mortality and liver failure.15 To our knowledge bisegmentectomy Sg7–8 without an IRHV has never been reported, because of the risk of Sg6 venous congestion.
Anatomic considerations Couinaud’s studies described hepatic venous anastomoses in 25 of 30 examined casts and their presence was demonstrated in Budd–Chiari syndrome.5,16 Two more studies reported venous anastomoses between the middle hepatic vein (MHV) and the RHV in half of the examined cases.17,18 Moreover, Masselot described a tributary of the MHV draining Sg6 running through Sg5 in 12% of 80 examined casts and Sano identified this branch with IOUS in about 13% of patients.4,19 Even though these anastomoses are described, it is unclear whether they would drain Sg6 completely after RHV occlusion.18 Color-Doppler evaluation Parenchymal venous congestion has been debated for reconstruction of the middle hepatic vein tributaries of the liver graft in living donor liver transplantation (LDLT) when the MHV is separated from the graft; in such a case there is the risk of congestion of the right paramedian sector (Sg5–8).19 Sano performed color-Doppler IOUS to check
Figure 2. Color-Doppler IOUS of the portal inflow in the right posterior portal branch before (a) and after (b) RHV clamping: the flow decreased (16 vs 11 cm/s) but remained hepatopetal.
L. Capussotti et al. / EJSO 32 (2006) 469–471
471
is mandatory to evaluate the vascular pattern of the remaining Sg6.
References
Figure 3. Bisegmentectomy Sg7–8: (a) liver surface without any discoloration after right hepatic artery occlusion; (b) raw cut surface at the end of parenchymal transection with ligated RHV.
hepatic venous and portal flow in the occlusive area after MHV clamping: in the presence of patent venous anastomoses, portal flow remained hepatopetal in Sg5–8 and hepatic venous flow in MHV was regurgitated in tributaries toward the RHV through anatomoses. On the other hand, if anastomoses did not work, portal flow became hepatofugal in the veno-occlusive area. Hepatic artery clamping confirmed color-Doppler IOUS results: if Sg5–8 were not drained by the RHV the congested area showed a discoloration on the liver surface during arterial clamping.19 We employed the same technique in our patient. After RHV clamping, color-Doppler IOUS showed that portal flow in Sg6 remained hepatopetal, even in presence of an inverted flow in the RHV; no ischemic discoloration on liver surface occurred after right hepatic artery occlusion. The information obtained from IOUS allowed us to perform a bisegmentectomy Sg7–8 with ligation of the RHV without any congestion of the remaining Sg6. This was possible thanks to the patency of anastomotic branches between the right and the middle hepatic veins. Parenchymal preservation in the face of venous congestion is still debated: Kaneko et al. reported that venous anastomoses can become patent and detectable by Doppler ultrasonography only 6 days after LDLT,20 but Sano reported relieved congestion in only 43% of patients.19 Intraoperative evidence of hepatofugal flow in portal branches for Sg6 after RHV occlusion or Sg6 discoloration after artery clamping should be considered a contraindication to Sg6 sparing. In conclusion, bisegmentectomy Sg7–8 in the absence of an IRHV is feasible; IOUS with color-Doppler study
1. Hemming AW, Reed AI, Howard RJ, Fujita S, Hochwald SN, Caridi JG, et al. Preoperative portal vein embolization for extended hepatectomy. Ann Surg 2003;237(5):686–91. 2. Chouillard E, Cherqui D, Tayar C, Brunetti F, Fagniez PL. Anatomical bi- and trisegmentectomies as alternatives to extensive liver resections. Ann Surg 2003;238(1):29–34. 3. Makuuchi M, Hasegawa H, Yamazaki S, Takayasu K. Four new hepatectomy procedures for resection of the right hepatic vein and preservation of the inferior right hepatic vein. Surg Gynecol Obstet 1987;164(1):68–72. 4. Masselot R, Leborgne J. E´tude anatomique des ve`ines sus-he`patiques. Anat Clin 1978;1:109–25. 5. Couinaud C. Le foie. E`tudes anatomiques et chirurgicales. Paris: Masson; 1957. 6. Chevallier JM. Anatomic basis of vascular exclusion of the liver. Surg Radiol Anat 1988;10:187–94. 7. Nakamura S, Tsuzuki T. Surgical anatomy of the hepatic veins and the inferior vena cava. Surg Gynecol Obstet 1981;152:43–50. 8. Champetier J, Haouari H, Le Bas JF, Letoublon C, Alnaasan I, Farah I. Large inferior right hepatic vein. Clinical implications. Surg Radiol Anat 1993;15(1):21–9. 9. De Cecchis L, Hribernik M, Ravnik D, Gadzijev EM. Anatomical variations in the pattern of the right hepatic veins: possibilities for type classification. J Anat 2000;197(Pt 3):487–93. 10. Makuuchi M, Hasegawa H, Yamazaki S, Bandai Y, Watanabe G, Ito T. The inferior right hepatic vein: ultrasonic demonstration. Radiology 1983;148(1):213–7. 11. Cheng YF, Huang TL, Chen CL, Chen TY, Huang CC, Ko SF, et al. Variations of the middle and inferior right hepatic vein: application in hepatectomy. J Clin Ultrasound 1997;25(4):175–82. 12. Adam R, Pascal G, Azoulay D, Tanaka K, Castaing D, Bismuth H. Liver resection for colorectal metastases: the third hepatectomy. Ann Surg 2003;238(6):871–83 [discussion 883–4]. 13. Farges O, Belghiti J, Kianmanesh R, Regimbeau JM, Santoro R, Vilgrain V, et al. Portal vein embolization before right hepatectomy: prospective clinical trial. Ann Surg 2003;237(2):208–17. 14. Hamy A, d’Alincourt A, Floch I, Madoz A, Paineau J, Lerat F. Bisegmentectomy 7–8: importance of preoperative diagnosis of a right inferior hepatic vein. Ann Chir 2004;129(5):282–5. 15. Muratore A, Conti P, Amisano M, Bouzari H, Capussotti L. Bisegmentectomy 7–8 as alternative to more extensive liver resections. J Am Coll Surg 2005;200(2):224–8. 16. Maguire R, Doppman JL. Angiographic abonrmalities in partial Budd– Chiari syndrome. Radiology 1977;122:629–35. 17. Lasinski W, Zientarski B. The anastomotic system of sub-hepatic veins in man. Bull Assoc Anat (Nancy) 1976;60(170):559–66. 18. Hribernik M, de Cecchis L, Trotovsek B, Gadzijev EM, Ravnik D. Anatomical variations of the right hepatic veins and their relevance to surgery. Hepatogastroenterology 2003;50(51):656–60. 19. Sano K, Makuuchi M, Miki K, Maema A, Sugawara Y, Imamura H, et al. Evaluation of hepatic venous congestion: proposed indication criteria for hepatic vein reconstruction. Ann Surg 2002;236(2):241–7. 20. Kaneko T, Kaneko K, Sugimoto H, Inoue S, Hatsuno T, Sawada K, et al. Intrahepatic anastomosis formation between the hepatic veins in the graft liver of the living related liver transplantation: observation by Doppler ultrasonography. Transplantation 2000;70(6):982–5.