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Reconstruction of portal vein using a hepatic vein patch graft after combined hepatectomy and portal vein resection
The American Journal of Surgery 185 (2003) 230 –231
How I do it
Reconstruction of portal vein using a hepatic vein patch graft after combined hepatectomy and portal vein resection Kurumboor Prakash, M.Ch., Jean-Marc Regimbeau, M.D.a, Jacques Belghiti, M.D.* a
Department of Hepatopancreatic and Biliary Surgery, Beaujon Hospital, 100 boulevard du Ge´ne´ral Leclerc, Assistance Publique Hoˆpitaux de Paris, University Paris VII, 92118 Clichy, France Manuscript received April 30, 2002; revised manuscript September 1, 2002
Abstract Background: Surgical resection is the only treatment modality that ensures complete tumor removal in patients with liver tumors involving a major portal vein branch or its bifurcation. Restoration of good portal blood flow is essential for recovery in the early postoperative period and for long-term survival. However, such extended resections often result in large defects at the bifurcation of the portal vein that are not amenable to suturing or end-to-end anastomosis. Methods: A patch graft technique is very useful for reconstruction of long and elongated defects when other methods are not technically appropriate. We describe a simple technique for reconstructing the portal vein using a patch graft obtained from the hepatic vein stump of the resected specimen. Conclusions: This technique permits surgeons to reconstruct the portal vein without any need for harvesting another vein and with no need for an additional incision. © 2003 Excerpta Medica Inc. All rights reserved. Keywords: Patch-graft; Hepatic vein; Portal vein involvement; Portal vein reconstruction
Resection of liver tumors involving major branches of the portal vein or a portion of its bifurcation is being increasingly performed in current surgical practice. Such resection with the involved portal vein branches often results in a large defect at the confluence of the portal vein. These defects are managed either by primary suture closure with venoplasty, or by resection and end-to-end anastomosis, or by using interposed vascular grafts or prosthetic materials. When the defect is large and elongated, however, suturing or resection and anastomosis may not be technically feasible. As thrombosis of the portal vein during the early postoperative period has disastrous consequences, reconstruction of a portal vein defect has to be performed carefully to avoid narrowing or kinking. Reconstruction of a portal vein defect has been described using ovarian vein graft [1], saphenous vein graft [2], internal jugular vein graft [3], and bypass graft [4], and experimentally with peritoneal patch graft [5]. Extra incisions are often needed for these procedures, however, and these procedures may not be applicable to all patients. We describe a technique for portal vein * Corresponding author. Tel.: 33-1-4087-5895; fax: ⫹33-1-4087-1724. E-mail address: [email protected]
reconstruction using a hepatic vein patch graft harvested from the hepatic vein stump of the specimen after hepatectomy, which is usually uninvolved and away from the tumor.
Surgical technique Resection of the involved major branch or a part of the bifurcation of portal vein is done between two vascular clamps applied to the main portal trunk and distal to the resection, respectively, to obtain a tumor-free margin of 2 to 3 mm (Fig. 1). The defect is temporarily closed using continuous sutures to restore blood supply to the future remnant liver until hepatectomy is completed. A segment of hepatic vein measuring about 2 cm is harvested after hepatic resection from the resected liver (Fig. 2, A). The liver tissue on the adventitial surface of the vein is trimmed off, small openings of the hepatic vein tributaries are closed, and the vein is cut longitudinally (Fig. 2, B). A patch graft thus obtained is applied over the defect with the intimal surface facing inside the lumen and sutured with 5-0 prolypropelene suture to cover the defect without luminal compromise (Fig. 2, C).
0002-9610/03/$ – see front matter © 2003 Excerpta Medica Inc. All rights reserved. doi:10.1016/S0002-9610(02)01360-0
K. Prakash et al. / The American Journal of Surgery 185 (2003) 230 –231
231
cinoma with involvement of the portal vein bifurcation. There was no rethrombosis of the reconstructed portal vein during the immediate postoperative period and no patients experienced late rethrombosis. Comments
Fig. 1. (Top left) Contrast-enhanced computed tomography scan and (top right) portography showing hepatocellular carcinoma with tumor thrombosis involving right branch and the confluence of the portal vein. (Bottom) Portal vein after resection of the involved major branch and a part of the bifurcation.
The patients are placed on a regimen of anticoagulant therapy postoperatively (low molecular heparin during the postoperative period and oral anticoagulants thereafter for 3 months). The immediate postoperative course is monitored with special attention paid to the occurrence of rethrombosis to the reconstructed vessel. Doppler ultrasonography was performed twice daily for 48 hours and daily thereafter for 5 days. This technique has been used with 5 patients with hepatocellular carcinoma with thrombus involving the portal vein bifurcation and 3 patients with hilar cholangiocar-
Aggressive resection of liver tumors with involvement of the major branches of the portal vein has been shown to provide good results [6,7]. Wu et al [7] has reported a high incidence of intramural infiltration of cancer cells at the site of adhesion of the thrombus to the portal vein. A resection with curative intent thus requires excision of a segment of portal vein with a tumor-free margin of 2 to 3 mm. Similarly, resection of portal vein is necessary to ensure en-bloc resection of locally advanced hilar cholangiocarcinoma with direct invasion of the portal vein [8]. Such resection of portal vein branches or a portion of its bifurcation often results in a large defect measuring more than 3 cm on the long axis. Our technique is a simple and effective method to reconstruct large portal vein defects after combined hepatic and portal vein resection. This clinical situation typically arises after the resection of right portal vein branches in a patient with portal trifurcation or after the resection of a part of the portal bifurcation when the tumor thrombus is very close to the bifurcation. The patch graft from the hepatic vein should only be taken if it is far away from the tumor and if there is no tumor thrombus in the hepatic vein. Hepatic vein patch grafts may be useful for vascular reconstruction of a liver transplant as well, and a graft could be harvested from the resected liver of the recipient. A patch graft measuring 4 ⫻ 2 cm can be easily obtained from the hepatic vein to reconstruct these defects. References
Fig. 2. (Left, and top right) Harvesting of the hepatic vein segment. (Bottom right) Patch graft sutured to the portal vein defect.
[1] Kubota K, Makuuchi M, Sugawara Y, et al. Reconstruction of the hepatic and portal veins using a patch graft from right ovarian vein. Am J Surg 1998;176:295–7. [2] Urayama H, Kanamaru H, Matsumoto I, et al. Reconstruction of jugular and portal blood flows using remodelled great saphenous vein graft. Surg Today 1993;23:936 – 8. [3] Takayama Y, Kanamaru H, Yokohama H, et al. Portal vein reconstruction using an internal jugular vein as a graft: report of a case. Surg Today 1995;25:378 – 80. [4] Kumuda K, Ozawa K, Okamoto R, et al. Hepatic resection for advanced hepatocellular carcinoma with portal vein tumour thrombi. Surgery 1990;108:821–7. [5] Yashioka M, Onda M, Tajiri T, et al. Reconstruction of portal vein using a peritoneal patch-graft. Am J Surg 2001;181:247–50. [6] Ohkubo T, Yamamoto J, Sugawara Y, et al. Surgical results for hepatocellular carcinoma with macroscopic portal vein tumour thrombosis. J Am Coll Surg 2000;191:657– 60. [7] Wu CC, Hseih SR, Chen JT, et al. An appraisal of the liver and portal vein resection for hepatocellular carcinoma with tumour thrombi extending to portal bifurcation. Arch Surg 2000;135:1273–9. [8] Neuhaus P, Jonas S, Bechstein WO, et al. Extended resections for hilar cholangiocarcinoma. Ann Surg 1999;230:808 –18.
How I do it
Reconstruction of portal vein using a hepatic vein patch graft after combined hepatectomy and portal vein resection Kurumboor Prakash, M.Ch., Jean-Marc Regimbeau, M.D.a, Jacques Belghiti, M.D.* a
Department of Hepatopancreatic and Biliary Surgery, Beaujon Hospital, 100 boulevard du Ge´ne´ral Leclerc, Assistance Publique Hoˆpitaux de Paris, University Paris VII, 92118 Clichy, France Manuscript received April 30, 2002; revised manuscript September 1, 2002
Abstract Background: Surgical resection is the only treatment modality that ensures complete tumor removal in patients with liver tumors involving a major portal vein branch or its bifurcation. Restoration of good portal blood flow is essential for recovery in the early postoperative period and for long-term survival. However, such extended resections often result in large defects at the bifurcation of the portal vein that are not amenable to suturing or end-to-end anastomosis. Methods: A patch graft technique is very useful for reconstruction of long and elongated defects when other methods are not technically appropriate. We describe a simple technique for reconstructing the portal vein using a patch graft obtained from the hepatic vein stump of the resected specimen. Conclusions: This technique permits surgeons to reconstruct the portal vein without any need for harvesting another vein and with no need for an additional incision. © 2003 Excerpta Medica Inc. All rights reserved. Keywords: Patch-graft; Hepatic vein; Portal vein involvement; Portal vein reconstruction
Resection of liver tumors involving major branches of the portal vein or a portion of its bifurcation is being increasingly performed in current surgical practice. Such resection with the involved portal vein branches often results in a large defect at the confluence of the portal vein. These defects are managed either by primary suture closure with venoplasty, or by resection and end-to-end anastomosis, or by using interposed vascular grafts or prosthetic materials. When the defect is large and elongated, however, suturing or resection and anastomosis may not be technically feasible. As thrombosis of the portal vein during the early postoperative period has disastrous consequences, reconstruction of a portal vein defect has to be performed carefully to avoid narrowing or kinking. Reconstruction of a portal vein defect has been described using ovarian vein graft [1], saphenous vein graft [2], internal jugular vein graft [3], and bypass graft [4], and experimentally with peritoneal patch graft [5]. Extra incisions are often needed for these procedures, however, and these procedures may not be applicable to all patients. We describe a technique for portal vein * Corresponding author. Tel.: 33-1-4087-5895; fax: ⫹33-1-4087-1724. E-mail address: [email protected]
reconstruction using a hepatic vein patch graft harvested from the hepatic vein stump of the specimen after hepatectomy, which is usually uninvolved and away from the tumor.
Surgical technique Resection of the involved major branch or a part of the bifurcation of portal vein is done between two vascular clamps applied to the main portal trunk and distal to the resection, respectively, to obtain a tumor-free margin of 2 to 3 mm (Fig. 1). The defect is temporarily closed using continuous sutures to restore blood supply to the future remnant liver until hepatectomy is completed. A segment of hepatic vein measuring about 2 cm is harvested after hepatic resection from the resected liver (Fig. 2, A). The liver tissue on the adventitial surface of the vein is trimmed off, small openings of the hepatic vein tributaries are closed, and the vein is cut longitudinally (Fig. 2, B). A patch graft thus obtained is applied over the defect with the intimal surface facing inside the lumen and sutured with 5-0 prolypropelene suture to cover the defect without luminal compromise (Fig. 2, C).
0002-9610/03/$ – see front matter © 2003 Excerpta Medica Inc. All rights reserved. doi:10.1016/S0002-9610(02)01360-0
K. Prakash et al. / The American Journal of Surgery 185 (2003) 230 –231
231
cinoma with involvement of the portal vein bifurcation. There was no rethrombosis of the reconstructed portal vein during the immediate postoperative period and no patients experienced late rethrombosis. Comments
Fig. 1. (Top left) Contrast-enhanced computed tomography scan and (top right) portography showing hepatocellular carcinoma with tumor thrombosis involving right branch and the confluence of the portal vein. (Bottom) Portal vein after resection of the involved major branch and a part of the bifurcation.
The patients are placed on a regimen of anticoagulant therapy postoperatively (low molecular heparin during the postoperative period and oral anticoagulants thereafter for 3 months). The immediate postoperative course is monitored with special attention paid to the occurrence of rethrombosis to the reconstructed vessel. Doppler ultrasonography was performed twice daily for 48 hours and daily thereafter for 5 days. This technique has been used with 5 patients with hepatocellular carcinoma with thrombus involving the portal vein bifurcation and 3 patients with hilar cholangiocar-
Aggressive resection of liver tumors with involvement of the major branches of the portal vein has been shown to provide good results [6,7]. Wu et al [7] has reported a high incidence of intramural infiltration of cancer cells at the site of adhesion of the thrombus to the portal vein. A resection with curative intent thus requires excision of a segment of portal vein with a tumor-free margin of 2 to 3 mm. Similarly, resection of portal vein is necessary to ensure en-bloc resection of locally advanced hilar cholangiocarcinoma with direct invasion of the portal vein [8]. Such resection of portal vein branches or a portion of its bifurcation often results in a large defect measuring more than 3 cm on the long axis. Our technique is a simple and effective method to reconstruct large portal vein defects after combined hepatic and portal vein resection. This clinical situation typically arises after the resection of right portal vein branches in a patient with portal trifurcation or after the resection of a part of the portal bifurcation when the tumor thrombus is very close to the bifurcation. The patch graft from the hepatic vein should only be taken if it is far away from the tumor and if there is no tumor thrombus in the hepatic vein. Hepatic vein patch grafts may be useful for vascular reconstruction of a liver transplant as well, and a graft could be harvested from the resected liver of the recipient. A patch graft measuring 4 ⫻ 2 cm can be easily obtained from the hepatic vein to reconstruct these defects. References
Fig. 2. (Left, and top right) Harvesting of the hepatic vein segment. (Bottom right) Patch graft sutured to the portal vein defect.
[1] Kubota K, Makuuchi M, Sugawara Y, et al. Reconstruction of the hepatic and portal veins using a patch graft from right ovarian vein. Am J Surg 1998;176:295–7. [2] Urayama H, Kanamaru H, Matsumoto I, et al. Reconstruction of jugular and portal blood flows using remodelled great saphenous vein graft. Surg Today 1993;23:936 – 8. [3] Takayama Y, Kanamaru H, Yokohama H, et al. Portal vein reconstruction using an internal jugular vein as a graft: report of a case. Surg Today 1995;25:378 – 80. [4] Kumuda K, Ozawa K, Okamoto R, et al. Hepatic resection for advanced hepatocellular carcinoma with portal vein tumour thrombi. Surgery 1990;108:821–7. [5] Yashioka M, Onda M, Tajiri T, et al. Reconstruction of portal vein using a peritoneal patch-graft. Am J Surg 2001;181:247–50. [6] Ohkubo T, Yamamoto J, Sugawara Y, et al. Surgical results for hepatocellular carcinoma with macroscopic portal vein tumour thrombosis. J Am Coll Surg 2000;191:657– 60. [7] Wu CC, Hseih SR, Chen JT, et al. An appraisal of the liver and portal vein resection for hepatocellular carcinoma with tumour thrombi extending to portal bifurcation. Arch Surg 2000;135:1273–9. [8] Neuhaus P, Jonas S, Bechstein WO, et al. Extended resections for hilar cholangiocarcinoma. Ann Surg 1999;230:808 –18.