Maki Harufumi, Satou Shouichi, Nakajima Kentaro, Nagao Atsuki, Watanabe Kazuteru, Satodate Hitoshi, Nara Satoshi, Furushima Kaoru, Harihara Yasushi
Department of Surgery, NTT Medical Center Tokyo, 5-9-22 Higashi-Gotanda, Shinagawa-Ku, Tokyo, 141-8625, Japan.
Surg Case Rep. 2018 Feb 16;4(1):17. doi: 10.1186/s40792-018-0424-5.
Aggressive hepatectomy with venous resection has a higher risk of postoperative liver failure (POLF) than hepatectomy without venous reconstruction; however, venous reconstruction is technically demanding. We performed a novel two-stage hepatectomy (TSH) without venous reconstruction in a patient with bilobar multiple colorectal liver metastases located near the caval confluence, waiting for the development of intrahepatic venous collaterals between procedures.
A 60-year-old man was referred to our hospital with sigmoid colon cancer accompanied by intraabdominal abscess and two synchronous liver metastases. One of the liver tumors (tumor 1) was located in segment 8 near the caval confluence and was attached to both the right hepatic vein (RHV) and middle hepatic vein (MHV). The other tumor (tumor 2) in the left lobe invaded the umbilical portion of the portal vein. Both liver metastases decreased in size after four cycles of panitumumab/5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) therapy. Radical liver resection was planned because tumor 1 had not invaded the MHV. However, three-dimensional volumetric software showed that the non-congested volume of the future liver remnant was estimated at 354 ml, which corresponded to 26.3% of the total liver volume. TSH was scheduled to avoid POLF. We first performed limited resection of segment 8 with resection of the RHV root. After the first hepatectomy, the development of intrahepatic venous collaterals between the RHV and MHV was seen on computed tomography and magnetic resonance imaging. The estimated non-congested future liver remnant was 1242 ml, 78.5% of the total liver volume. Therefore, the patient underwent left hemihepatectomy 58 days after the first hepatectomy. We saw no adhesions around the porta hepatis, and the left hepatic artery and left branch of the portal vein were safely exposed and divided. Intraoperative Doppler ultrasonography revealed intrahepatic venous collaterals arising from RHV to MHV. The patient's postoperative course was uneventful, and he underwent eight cycles of panitumumab/FOLFOX therapy for 5 months after the second hepatectomy.
Our TSH strategy helped avoid POLF by waiting for the development of intrahepatic venous collaterals.
与未进行静脉重建的肝切除术相比，行静脉切除的根治性肝切除术术后肝衰竭（POLF）风险更高；然而，静脉重建技术要求较高。我们对一名肝门汇合处附近存在双侧多发结直肠癌肝转移的患者实施了一种新型的无静脉重建的两阶段肝切除术（TSH），在两次手术之间等待肝内静脉侧支循环的形成。
一名60岁男性因乙状结肠癌伴腹腔内脓肿及两个同时性肝转移灶被转诊至我院。其中一个肝肿瘤（肿瘤1）位于肝段8，靠近肝门汇合处，与右肝静脉（RHV）和肝中静脉（MHV）均相连。左叶的另一个肿瘤（肿瘤2）侵犯了门静脉脐部。在接受四个周期的帕尼单抗/5-氟尿嘧啶、亚叶酸钙和奥沙利铂（FOLFOX）治疗后，两个肝转移灶均缩小。由于肿瘤1未侵犯MHV，计划行根治性肝切除。然而，三维容积软件显示，未来肝残余的非充血体积估计为354 ml，占肝脏总体积的26.3%。为避免发生POLF，安排了TSH。我们首先对肝段8进行了有限切除并切除了RHV根部。第一次肝切除术后，在计算机断层扫描和磁共振成像上可见RHV和MHV之间肝内静脉侧支循环的形成。估计未来非充血性肝残余为1242 ml，占肝脏总体积的78.5%。因此，患者在第一次肝切除术后58天接受了左半肝切除术。我们在肝门周围未发现粘连，左肝动脉和门静脉左支得以安全显露并离断。术中多普勒超声检查显示有从RHV至MHV的肝内静脉侧支循环。患者术后恢复顺利，在第二次肝切除术后接受了五个月的八个周期的帕尼单抗/FOLFOX治疗。
我们的TSH策略通过等待肝内静脉侧支循环的形成有助于避免POLF。
