Procopio Fabio, Famularo Simone, Branciforte Bruno, Corleone Pio, Cimino Matteo, Viganò Luca, Donadon Matteo, Torzilli Guido
Division of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
Surgery. 2023 Feb;173(2):412-419. doi: 10.1016/j.surg.2022.07.017. Epub 2022 Aug 26.
Deep-located liver tumors involving hepatic veins at the caval confluence or main Glissonean pedicles generally require a major hepatectomy. An intraoperative ultrasound guidance policy opened a possibility to opt for parenchyma-sparing procedures as alternatives to major hepatectomy, called transversal hepatectomies. We ought to standardize the procedure and analyze the surgical outcome, oncological suitability, and salvageability.
This is a retrospective cohort study. All consecutive patients undergoing hepatectomies for liver tumors between January 2005 and August 2020 were reviewed. Transversal hepatectomies were classified as follows: upper transversal hepatectomy: resection of the posterosuperior segments along with at least 1 hepatic vein and preservation of the anteroinferior ones; roller coaster hepatectomy: transversal hepatectomy with tumor vessel detachment from at least 2 hepatic veins; and lower transversal hepatectomy: amputation of the distal portion of at least 1 hepatic vein with tumor vessel detachment from first/second-order Glissonean pedicles. Morbidity, mortality, local recurrences, and salvageability in cases of relapse were considered.
A total of 61 transversal hepatectomies were performed: 40 (66%) upper transversal hepatectomies, 19 (31%) roller coaster hepatectomies, and 2 (3%) lower transversal hepatectomies. The median preserved liver volume was 67% (range 41-86). Mortality was 0, and major morbidity was 6%. Local recurrence occurred in 7 (11%) patients. Ten out of 34 (29%) patients with liver-only recurrence received redo surgery.
Transversal hepatectomies offer a new parenchyma-sparing perspective for the management of complex tumor presentation, which would otherwise demand major tissue removal or even unresectability. Safety, adequate local control, and salvageability are further pillars of this approach herein systematized.
累及腔静脉汇合处肝静脉或肝门Glissonean蒂主干的深部肝脏肿瘤通常需要进行大范围肝切除术。术中超声引导策略为选择保留肝实质的手术作为大范围肝切除术的替代方案（即横向肝切除术）提供了可能。我们应该规范该手术并分析手术结果、肿瘤学适宜性和挽救性。
这是一项回顾性队列研究。对2005年1月至2020年8月期间所有因肝脏肿瘤接受肝切除术的连续患者进行了回顾。横向肝切除术分类如下：上横向肝切除术：切除后上段及至少1条肝静脉，保留前下段；过山车式肝切除术：横向肝切除术，肿瘤血管与至少2条肝静脉分离；下横向肝切除术：至少1条肝静脉远端部分切断，肿瘤血管与第一/二级Glissonean蒂分离。考虑了发病率、死亡率、局部复发情况以及复发病例的挽救性。
共进行了61例横向肝切除术：40例（66%）上横向肝切除术，19例（31%）过山车式肝切除术，2例（3%）下横向肝切除术。保留肝脏体积的中位数为67%（范围41%-86%）。死亡率为0，主要并发症发生率为6%。7例（11%）患者发生局部复发。34例仅肝脏复发的患者中有10例（29%）接受了再次手术。
横向肝切除术为复杂肿瘤的处理提供了一种新的保留肝实质的视角，否则这些肿瘤需要进行大范围组织切除甚至无法切除。安全性、充分的局部控制和挽救性是本方法在此系统化的进一步支柱。
