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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1310_Библиотеки_им_академика_М_И_Перельмана.pdf
1 Resection of Large Hepatocellular Carcinoma … 11
Fig. 1.6 CT scanning for the patient with HCC located in the right lobe. The arterial phase
showed identical HCC enhancement (a) and suspected diaphragm invasion (b), but no
lymphonode metastasis was presented; c, d the portal vein phase showed normal left branch of
the portal vein, and suspected tumor pressure or tumor thrombus in the right branch of the portal
vein; e, f the delayed phase showed the common branch of middle hepatic vein and left hepatic
vein (e), and indicated that the middle hepatic vein was pressed by the tumor (f). The right hepatic
vein could not be distinguished, probably was circled or pressed by the tumor
FLR/standardized liver volume (SLV) ratio > 20% was considered safe hepatectomy for patients with normal liver function, but >31% with impaired liver
function [11–13]. SLV was calculated according to the following formula:
−794.41 + 1267.28 body surface area (m
2
)[14]. For this patient, the FLR/SLV
ratio is 46% for right hemi-hepatectomy, indicating safe surgery.
12 B. Zhang et al.
Fig. 1.7 3D CT reconstruction and future liver remnant (FLR) estimation. a General view
(anterior) of the whole liver. Red color for artery; light blue for portal vein system; navy blue for
hepatic vein and IVC; pine for normal liver; and orange for tumor. b Posterior general view of the
whole liver. The middle hepatic vein was pressed to left by tumor, and the right hepatic vein was
not shown as a result of tumor growing. c The tumor is majorly located in segment 7 and 8,
partially in segment 5 and 6. d Future liver remnant after right hemi-hepatectomy. The middle
hepatic vein was protected and kept
In our center, we routinely perform 3-D CT reconstruction and calculate the
remnant liver volume (Fig. 1.7). In our experience, FLR/ body weight (BW) ratio > 0.8% is considered safe hepatectomy for patients with no cirrhotic live, but
>1% for those with cirrhotic liver. In this case, the total liver volume was
2216.7 cm
65.2%, FLR (left liver lobe) after right hemi-hepatectomy was 561.2 cm
3
, the tumor volume was 1444.6 cm3, the ratio of tumor/whole liver
3
, the FLR
(left liver lobe)/total liver ratio is 25.3%, the body weight of this patient is 45.6 kg,
the FLR (left liver lobe)/BW ratio is 1.2%.
The evaluation of present hepatic function was based on the Child-Pugh scoring
system [15]. This system has been widely accepted by clinicians to evaluate liver
function, and to predict postoperative recovery. This patient did not show any sign
of hepatic encephalopathy or ascites. ALB is 33 umol/L, total bilirubin and PT are
normal. Therefore, the liver function of this patient is Child-pugh A (score 6). In
addition, indocyanine green retention rate at 15 min (ICGR15) was examined to
1 Resection of Large Hepatocellular Carcinoma … 13
evaluate the liver functional reserve estimation [16–18]. The ICGR15 for this
patient is 4.8%, indicating normal liver functional reservation. Gastroscopy was
also performed and did not show obvious esophageal varices, indicating no portal
hypertension.
Nutritional assessment was performed at admission according to Subjective
Global Assessment (SGA) [19] and Nutrition Risk Index (NRI); 83.5–97.5 was
considered as mildly malnourished, while <83.5 was considered as severely malnourished [19–21]. NRI was calculated with the formula: 1.519 serum albumin
(Alb) (g/L) + 0.417 (current weight/usual weight) 100. Malnutrition was
considered if the patients met at least one of two criteria: [20, 21]: (1) NRI 100,
(2) any two of the following: current weight/ideal weight was 95%; serum
Alb 35.0 g/L; or serum prealbumin was 200 mg/L. This female patient had
mild malnutrition, as her serum prealbumin was 156 mg/L and NRI was 96.3%.
Management
Perioperative antiviral treatment was initiated as soon as the DNA level was
identified. Entecavir tablet 0.5 mg was orally administered every day without
interruption, and was administered via the nasogastric tube at the day of surgery.
We highlighted the role of antiviral therapy, as clinical studies has proved that
antiviral treatment for HBV relative HCC has the role of reducing postoperative
complications and prolonging tumor-free survival [22, 23].
Right hemi-hepatectomy was performed in an open surgery for this patient.
Laparoscopic hepatectomy was not considered, owing to the following factors:
(1) the tumor is too huge to expose under laparoscopy; (2) diaphragm invasion or
adhesion results in difficulty of right liver mobilization; (3) thrombectomy is
required in case that thrombus existed in the right branch of the portal vein, which is
hard to perform under laparoscopic surgery. Therefore, open surgery was performed
through a right subcostal incision with midline extension.
The Chen’s double-hanging maneuver was applied to assist liver parenchyma
transection (Fig. 1.8). In this case, the two-hanging tapes played the following
roles: (1) guide the transection plane; (2) hemorrhage control; (3) protect the middle
hepatic vein and IVC; (4) expose the transection tunnel; (5) minimize the pressure
of the tumor during operation to reduce tumor spreading. No bleeding presented
when we built the retrohepatic tunnel and set up the hanging tapes.
The whole liver parenchyma transection time is less than 30 min, and total
intraoperative hemorrhage is 150 ml. The middle hepatic vein and IVC were protected well. No tumor thrombus was observ ed in the portal vein system, after we
dissected the right branch of the portal vein. The remnant liver has light liver
cirrhosis, but its volume was more than enough for this thin wom an.
We provided omega-3 fatty acid-based parenteral nutrition for the patient for 5
days after surgery, as a lower content of n-6 unsaturated FA in lipid emulsion than
in conventional pure soybean oil emulsion was suggested by the European Society
of Enteral and Parental Nutrition (ESPEN) for cirrhotic patients [24]. Our
14 B. Zhang et al.
Fig. 1.8 Right hemi-hepatectomy with Chen’s double-hanging maneuver. a The kidney pedicle
forceps was inserted into the retrohepatic tunnel. b The tip of the kidney pedicle forceps passed
through the retrohepatic space and arrived at the right side of the suprahepatic IVC. Two tapes
around the liver are pulled toward the left and the right, respectively. c The MHV was exposed in
the transection plane of the remnant liver. d The tapes guided the transection plane and protect the
IVC. e The RHV was exposed and transected. f Remnant liver with MHV and IVC in the
transection plane. RPV right branch of portal vein; CB common bile duct; IVC inferior vena cava;
RHV right hepatic vein; MHV middle hepatic vein
unpublished clinical study provided evidences that this omega-3 fatty acid-based
parenteral nutrition improves postoperative recovery for cirrhotic patients with
HCC.
Outcome
The removed tumor mass showed adequate liver resection and negative transection
margin (Fig. 1.9). The tumor was 15 cm 10 cm 10 cm in size and showed
clear tumor margin. Histologic examination of the tumor was consistent with HCC
of moderate differentiation.
The patient in this case was discharged from the hospital 7 days after surgery.
Diet was started the 2 day after the operation, and liver function was recovered to
normal 3 days postoperatively. No major complication presented, except minor
pleural effusion that did not require any treatment.
AFP and ultrasonography were examined every month, while CT scanning and
HBV-DNA were examined every 3 months. After 13 months follow-up, CT
scanning did not shown recurrence or metastasis. HBV-DNA was controlled in the
normal level (<100 copies/ml). AFP level waved at different follow-up time point,
but lower than 500 ng/ml.
1 Resection of Large Hepatocellular Carcinoma … 15
Fig. 1.9 Tumor mass and pathology. a Removed tumor mass showed clear tumor margin and
en-block tumor resection. b Hematoxylin–eosin staining showed hepatocellular carcinoma with
moderate differentiation
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Debulking of Extensive Neuroendocrine Liver Metastases
Douglas L. Fraker and Steven K. Libutti
Introduction
The incidence of neuroendocrine tumors (NET) primarily in the mid-gut, but also of
the pancreas, has increased significantly over the past two decades. The cause for
this increase in incidence is not clear. Patients with mid-gut NET may present with
symptoms of diarrhea as well as flushing, but a large number of patients, despite
volume disease and elevated secretory products, may be asymptomatic. Similarly,
patients with pancreas NET often present as asymptomatic lesions of the liver.
These malignancies frequently metastasize to the liver and nowhere else. Patients
who die from this malignant disease typically succumb to liver failure.
Patients with NET metastatic to the liver frequency have large numbers of
lesions distributed evenly throughout the liver. The approach to these patients
surgically is very different from the approach employed in the more well-defined
patient population of metastatic colorectal cancer to the liver. Specifically, in
treatment of colon cancer metastasis, there are clear guidelines related to numbers
of lesions as well as the importance of doing a negative margin resection. For
debulking of metastatic neuroendocrine tumors to the liver, there is no limitation in
terms of number of lesions, and it is not important to have negative margins. In fact,
it is more appropriate to resect lesions right on their capsule. Also, it is felt that
2
D.L. Fraker
Department of Surgery, University of Pennsylvania, 4 Silverstein, 3400 Spruce Street,
Philadelphia, PA 19104, USA
e-mail: frakerd@uphs.upenn.edu
S.K. Libutti (&)
Montefiore Medical Center and Albert Einstein College of Medicine, 3400 Bainbridge
Avenue, 4th Floor, Bronx, NY 10467, USA
e-mail: slibutti@montefiore.org
© Springer International Publishing AG 2017
T.M. Pawlik et al. (eds.), Case-Based Lessons in the Management of Complex
Hepato-Pancreato-Biliary Surgery, DOI 10.1007/978-3-319-50868-9_2
17
18 D.L. Fraker and S.K. Libutti
surgical debulking is beneficial to patients even if up to 30% of the disease is not
able to be treated.
Case 1: Mid-Gut Neuroendocrine Tumor Metastatic to the Liver
The patient is a 62-year-old man with a past history of papillary thyroid cancer 6
years earlier, in complete remission, who presented with flushing and a change in
bowel habits with going from one bowel movement per day to two to three loose
bowel movements per day. He had imaging with CT scan that showed a dominant
6 cm right inferior segment hepatic lesion, additional lesions up to 3 cm in the right
hepatic lobe, a 3 cm caudate metastasis, and small lesions in the left liver (Fig. 2.1).
The pancreas appeared normal, and the official reading said there was no evidence
of any small bowel lym phadenopathy or lesions in the small intestine. A biopsy was
performed of the large level 6 lesion and it showed a metastatic neuroendocrine
tumor. Twenty-four hour urinary 5HIAA was elevated at 13 mg/24 h (upper limits
of normal 7.5). He was treated with Sandostatin, with resolution of his flushing and
improvement in his bowel function. No other efforts at treatment and no endoscopic
Fig. 2.1 Intraoperative
picture of left lobe of liver in
patient with metastatic small
bowel NET to the liver. Large
8 cm lesion in inferior right
lobe with other lesions in
right lobe and caudate.
Multiple small lesions in left
liver make it clear that there is
no curative option, and also
demonstrates why right
hepatectomy is not indicated
due to extensive contralateral
disease
2 Debulking of Extensive Neuroendocrine Liver Metastases 19
studies were performed at an outside institution. An initial interval scan at 6 months
showed an increase in size of his right segment 6 hepatic metastasis from 6 cm up
to 8 cm. The remaining lesions were stable, and no new lesions appeared and there
were no other findings. He was referred to our multidisciplinary neuroendocrine
tumor group.
An octreoscan was obtained and it showed activity in the hepatic metastasis; no
activity in the small bowel mesentery, small bowel, or pancreas. Serum serotonin
was elevated at 1,433 ng/mL (normal range 85–220). We performed upper endoscopy and colonoscopy, which showed no lesions. He had a capsule endoscopy
which was negative.
He was seen in surgical consultation and was recommended to have an exploration with liver debulking, including intraoperative identification of his mid-gut
primary and planned resection. He had been receiving monthly Sandostatin injections, and an intravenous Sandostatin drip was prepared for infusion as needed for
carcinoid storm. The approach was right subcostal incision with extension to the left
side. The lateral aspects of the subcostal incision was not curved superiorly as is
typical for right hepatic lobectomy, but rather went more inferiorly to allow
exploration of the abdominal cavity for his primary to facilitate exploration of the
abdominal cavity for a primary lesion. The initial part of the operation was to assess
the primary. It was found immediately on palpation of the distal small bowel which
was in the pelvis. The hepatic flexure of the colon and area of the ileo-cecal valve
was completely mobilized with some tethering of the primary lesion and palpable
lymph nodes in a loop of distal small bowel mesentery in the pelvis. This distal
small bowel was brought up into the subcostal incision and there was careful
palpation of the bowel from the ligament of Treitz to the ileocecal valve. The
solitary lesion approximately 8 cm proximal to ileocecal valve was the only mass
palpated. This had not been visualized by colonoscopy.
For mid-gut NET that are more than 20% proximal to the ileocecal valve, every
effort is made to try to preserve the ileocecal valve and do a segmental small bowel
resection. At this site and with the location of the lymph node metastasis necessitating resection of the right colic trunk, a right hemicolectomy with resection of
segment of small bowel and nodal metastasis was performed with standard anastomosis. Once the bowel resection and anastomsis was completed, the retractors
were completely shifted from exposi ng the lower aspect of the abdomen to
exposing the liver. The live r was completely mobilized and assessed by palpation
and intraoperative ultrasound. The dominant segment 6 lesion was easily felt, there
were four to five additional lesions in the right lobe > 1 cm and a large palpable
caudate mass. The left and right liver had multiple small palpable metastases
(Fig. 2.2). A cholecystectomy was performed. In this case, it was not necessary to
remove the gallbladder to address any of the hepatic nodules, but for patients with
NET with a laparoscopic approach, or certainly with an open approach liver
metastasis, it is mandatory to remove the gallbladder as long-term use of Sandostatin will lead to formation of gallstones and ability to approach the gallbladder
laparoscopically is compromised after such an extensive hepatic debulking procedure. To address the dominant lesion in the right segment 6, the right hepatic lobe
20 D.L. Fraker and S.K. Libutti
Fig. 2.2 Axial MRI of patient with metastatic NET to liver. Large right segment 6 lesion has
grown significantly over 6-month interval (large arrow). Caudate lesion is second largest tumor
(small arrow). At laparotomy, attempts were made to remove this lesion, but concerns over
damaging left portal triad resulted in radiofrequency ablation of this tumor
was completely mobilized off the inferior vena cava. The feeding vasculature from
the inferior segmental portal triad was assessed by surgeon-directed ultrasound and
entered the lesion at the inferior medial border of this mass. The approach was to
identify the margin of this large hepatic metastasis in a lateral avascular area. As is
typical, it was firm, white, and once we were on the capsule either with blunt
dissection with a finger or with a right angle, the surrounding parenchyma was
swept away. When bridging vessels were seen, they were controlled with clips or
Aquamontys ablation. Intraoperative ultrasound-guided dissection to where the
main trunk was plastered over this and a vascular stapler was used to divide the
main trunk. This large lesion was removed with very little surrounding parenchyma
and very little blood loss (Fig. 2.3a). The cut parenchyma of the base was controlled with argon beam laser. All other small nodules were then addressed. Any
nodule larger than 5 mm on the surface was resected with cautery and some exophytic lesions sharply resected with the base treated with cautery. Lesions just
under the surface in the range of 1–3 cm had a circular incision made with cautery
right over the palpable nodule. Once the white capsule of the nodule was identified,
again blunt dissection either with the finger or right angle clamp was used to go
around this often resecting 3 cm lesions in under 30 s. Several small 2–4mm
lesions were controlled with Aquamontys ablation on the surface with the typical
popping noise (Fig. 2.3b). Ultrasound revealed two lesions, one in the caudate that
was medially posterior to the main left segmental portal triad (Fig. 2.1) and a
second lesion that was deep anterior to the right portal triad. An attempt was made
to enucleate the caudate lesion, but it was too close to the main left portal structures.