Liver Surgery Unit, Third Department of Surgery, University of Milan School of Medicine, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy.
Ann Surg Oncol. 2010 Feb;17(2):483. doi: 10.1245/s10434-009-0728-6. Epub 2009 Oct 23.
In case of liver tumors invading the middle hepatic vein (MHV) at the hepatocaval confluence (HC) major resection is recommended. We describe a new ultrasound-guided conservative operation for patients with colorectal liver metastasis (CLM) invading the MHV at the HC.
The case of a 65-year-old woman with two CLMs is described. One CLM was in segments 4-superior (S4-superior) and 8-ventral (S8-ventral) with invasion of the MHV 2 cm from the HC, while the other was in segment 8-dorsal (cranial portion). J-shaped laparotomy and intraoperative ultrasonography (IOUS) were carried out. Anterior surface of the HC was exposed, and compression using the surgeon's fingertips was applied at the MHV. Once reversal flow in the peripheral portion of the MHV, and/or shunting collaterals with right or left hepatic vein, and/or hepatopetal flow in portal branches to right paramedian section (P5-8) and/or to segment 4-inferior (P4-inferior) were detected by color Doppler IOUS (CD-IOUS), partial resection of S4-superior and S8-ventral with vascular resection of MHV was performed.
The disclosure of those three criteria by CD-IOUS enables the performance of minimesohepatectomy. No congestion of the remnant liver was found. Ninety-day mortality and morbidity were nil. The patient was discharged 8 days after surgery. At 11 months of follow-up the patient underwent percutaneous radiofrequency ablation for a new 15-mm CLM in segment-8-dorsal (caudal portion). Currently, the patient is alive and free of disease at 17 months after surgery.
The use of CD-IOUS may allow conservative resection of liver tumors invading the MHV at the HC. This might limit the need for larger resections, and broadens the role of IOUS in optimizing surgical strategy.
在肝肿瘤侵犯肝中静脉（MHV）与肝静脉汇合处（HC）的情况下，建议进行主要切除术。我们描述了一种新的超声引导下的保守手术方法，用于治疗侵犯 HC 处 MHV 的结直肠癌肝转移（CLM）患者。
我们描述了一位 65 岁女性的病例，该女性有两个 CLM，一个位于 S4-superior 和 S8-ventral 段，侵犯了距离 HC 2cm 的 MHV，另一个位于 S8-dorsal（头部）段。进行 J 形剖腹手术和术中超声检查（IOUS）。暴露 HC 的前表面，并在 MHV 处使用术者指尖进行压迫。一旦彩色多普勒 IOUS（CD-IOUS）检测到 MHV 外周的逆行血流，以及/或右或左肝静脉的分流侧支，和/或门静脉分支向右侧旁正中段（P5-8）和/或下段 4（P4-inferior）的向肝性血流，就进行 S4-superior 和 S8-ventral 的部分切除和 MHV 的血管切除。
CD-IOUS 揭示了这三个标准，从而能够进行最小间肝切除术。未发现残留肝脏充血。90 天死亡率和发病率均为零。患者术后 8 天出院。在 11 个月的随访中，患者因新的 15mm 位于 S8-dorsal（尾部）段的 CLM 而行经皮射频消融术。目前，患者术后 17 个月仍存活且无疾病。
CD-IOUS 的使用可能允许对侵犯 HC 处 MHV 的肝肿瘤进行保守性切除。这可能限制了更大切除的需要，并扩大了 IOUS 在优化手术策略中的作用。
