Vascular Resection During Hepatectomy for Liver Malignancies. Results from a Tertiary Center using Autologous Peritoneal Patch for Venous Reconstruction

Abstract

Background To evaluate early outcomes of venous reconstruction with peritoneal patch (PP) during resection for hepatic malignancies. Methods Since May 2015, PP was considered as the first option for venous reconstruction in the case of lateral resection. Between May 2015 and June 2019, 579 consecutive hepatectomies for malignancies were performed at our institution. Among 27 patients requiring venous resection, PP was used in 22, who were included in the present study. Data from a prospectively collected database were analysed. Results Tumour types were ten colorectal metastases (CRLM), six intrahepatic cholangiocarcinomas, four hilar cholangiocarcinomas, one hepatocellular carcinoma and one gallbladder carcinoma. Hepatectomies were major in 50% of cases. Eleven patients had hepatic vein resections, eight portal vein and three inferior vena cava. Venous reconstruction enabled resection in 12 (54.5%) patients, otherwise non‐resectable. Among CRLM, the venous reconstruction allowed avoidance of major resection in eight (80%) cases. Median operative time was 456 min (range 270–960). Blood loss was a median 300 cc (range 40–1500), and blood transfusions were required in three patients (13.6%). At pathological examination, venous infiltration was confirmed in 14 (63.6%) patients. No vascular complications related to the patch were recorded. Post‐operative major (Dindo III/IV) complications were observed in two (9%) patients. One patient died because of liver failure without vascular thrombosis and one due to biliary fistula complicated by arterial bleeding. Overall, post‐operative mortality was 9% (2/22). Conclusions Venous reconstruction with peritoneal patch during hepatectomy for malignancies can feasibly allow resection in otherwise unresectable patients and decrease the rate of major resection in colorectal liver metastases.

Vascular Involvements in Cholangiocarcinoma: Tips and Tricks

“…A peritoneal patch can be retrieved from the peritoneum anterior to the renal fascia, right hypochondrium, falciform ligament or the anterior abdominal wall (possibly including the posterior rectus sheath), trimmed to fit the defect and sutured in place [31][32][33]. Major IVC Involvement below Hepatocaval Confluence When IVC involvement is greater than 60-120 • circumferentially and/or 2-3 cm longitudinally, side clamping could be impossible and a full IVC clamp might be mandatory.…”

“…A peritoneal patch can be retrieved from the peritoneum anterior to the renal fascia, right hypochondrium, falciform ligament or the anterior abdominal wall (possibly including the posterior rectus sheath), trimmed to fit the defect and sutured in place [31][32][33]. Pulitano et al used a peritoneal patch for 21 IVC repairs, reporting no vascular complica-tions related to the patch [31].…”

“…In any case, the reconstructive phase necessitates TVE of the liver and HP (as described above), as well as porto-systemic or portocaval shunting, which can be considered depending on the time needed for reconstruction [36,58]. Reconstruction of the hepatic vein may include a patch, or anastomosis to the IVC or an IVC prosthesis [19,33,58]. Options for reconstruction include direct anastomosis, synthetic grafts, cryopreserved vein grafts or autologous grafts.…”

“…During extended left hepatectomy, the main PV and right posterior branch could feature a large size discrepancy. For these reasons, wedge resections are more commonly attempted on the right side, followed by direct suture closure or patch closure (using cadaveric vein/peritoneum) [33,70,87]. Ebata et al reported direct closure to be appropriate in most cases (90%) [70].…”

Recurrence after Curative Resection for Intrahepatic Cholangiocarcinoma: How to Predict the Chance of Repeat Hepatectomy?

“…In the case of vascular infiltration, when major venous resection was required, the reconstruction was accomplished by peritoneal patch [21] or end-to-end anastomosis, as appropriated.…”