Surgery for liver tumors that are close to major vascular structures of future liver remnant

Abstract

Introduction: In patients with just enough future liver remnant (FLR) parenchymal transection preserving all the inflow or venous outflow of FLR is very important. Tumors close to the major hilar vessels or to the outflow of FLR pose unique challenges for assessment of resectability. In both benign and malignant conditions which are close to major vessels of FLR meticulous surgery is required to obtain good outcomes. Hence, we looked at the data of such tumors which are close to the inflow and outflow of FLR and studied the surgical feasibility and perioperative outcomes. Aim: The aim of the present study was to study the perioperative results of resection of tumors close to the inflow or outflow of future liver remnant. Material and methods:The study was a retrospective study conducted in the Department of Surgical Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad between 2015 to 2018.All tumors of the liver which were close (<1cm) to the inflow or outflow of the FLR were included in the study. Both benign and malignant tumors close to major vasculature of FLR were included. The surgical feasibility, complications and R0 resection rate was studied. Intraoperative and postoperative complications were studied. Results: Twenty three patients were included in the study. The mean age of the patients was 43.8(8-68) yrs. There were 8 patients with tumors close to outflow, 9 to inflow and 6 to both inflow and outflow of FLR. Preoperatively the diagnosis was benign in 6 (6/23, 26%). They were included in the study because of their critical location and proximity to the vasculature of FLR. Seven patients had a large SOL in liver (>9cm). One patient underwent 2 stage hepatectomy because of hemodynamic instability. The final histopathology was HCC in 4, Hepatoblastoma 1, Adenoma 1 and Tuberculosis in 1. Seven patients with hilar mass underwent surgery (3 had hilar cholangiocarcinoma, 1 intrahepatic cholangiocarcinoma and 3 benign). Segmentectomy was done in 3 (1 colorectal liver metastasis, 2 HCC with CLD) The final biopsy was malignancy in 12 patients. Two (2/12, 16.6%) of them had a positive resection margin). Five patients (5/ 17, 29%) with preoperative suspicion of malignancy had a benign etiology (1 adenoma, 2 tuberculosis, 2 granular cell tumor) on final histopathology. There was 1(1/23, 4.3%) mortality in our series due to bile leak and fungal sepsis. Two patients had transient liver failure (Grade II). Six (5 Grade II, 1 Grade V) patients had transient bile leak. Conclusion: Tumors close to inflow or outflow of FLR can be resected with acceptable morbidity and mortality.