Major Liver Resection

for
Primary and Metastatic Liver Tumor

dr.Budi Irwan,SpB-KBD
Divisi Bedah Digestif
FK-USU/RSUP HAM
 ISSUES

I. JUSTIFICATION

II. SURGICAL TECHNIQUES

III.MEDAN EXPERIENCES (2009-2012)

I. JUSTIFICATION
II. SURGICAL TECHNIQUES

III. MEDAN EXPERIENCES

Case 1. HCC S4,5,6,7,8 (FLRV 25%)

Male
47 yo
H:164cm
W:49 kg

AFP :>1000
Bilirubin : 1.4/0.8
Alb : 3.1

Child-Pugh A
Cirrhotic liver

ICG : No
TACE : No
 Barcelona-Clinic Liver Cancer

Major Liver Resection ?? = NO WAY !!

NCCN Guidelines 2013
 Algorithm for HCC
Japan Evidanced-Based Treatment

Kudo. Management of HCC in Japan. 2010

 Algorithm for HCC
Japan Consensus-Based Treatment€

Kudo. Management of HCC in Japan. 2010

 WHAT WE DID ?

1.Open PVE
 No CT
 4 weeks
 Stable
2.R.Trisectionectomy
 R.J.Thoraco-abd
 Blle leaks 2 weeks

03.09 - 11.12
3 years 8 months
Case 2 CRC-LM (synchronous)

September 2011
male,44 yo
Well-diff AdenoCa Rectum proximal
T4aN1cM1b
Synchronous Liver Mets S 2,3,4,6
Mechanical bowel obstruction
Child-pugh A
ANTERIOR RESECTION
Folfox-4 (4 cycles,2½ months)
Mild-respons
FLRV : 45%
Non-cirrhotic liver
NCCN Guidelines 2013
Changing paradigma for unresectable CRC-LM

Traditional Contemporary
 >4 noduls  Inability R0
 Size > 5 cm
 Bilateral
 Surgical margin<1cm  Positive margin
 Extra-hepatic nodul  Inability to resect all
detectable mets
 Scoring system  Disease progress
during chemoTx
Initially Unresectable Liver Mets CRC

Rene Adams. Oncosurgical strategies for unresectable liver metastases. 2009

Conversion to resectability

Rene Adams. Liver Metastases,2009

 Improve Resectability

1. Portal Vein Embolization

2. Liver resection + RFA/Cryo-surgery
3. Two stage hepatectomy
4. Neo-adjuvant/Conversion chemotherapy
 Sept 2011 - Now (22 months)

S2

S4

S3
 I. JUSTIFICATION

II.SURGICAL TECHNIQUES
III. MEDAN EXPERIENCES
 BRISBANE 2000
Nomenclature of Liver Resection
Makuuchi's criteria
Outcome Hepatectomy
 Hepati vein Left PV
CT SEGMENTATION

Right PV Splenic Vein

Dissection of Liver Hillar
 I. JUSTIFICATION

II. SURGICAL TECHNIQUES

III.MEDAN EXPERIENCES

(2009-2012)
 Major Hepatic Resection

Primary Liver Cancer Secondary Liver Mets

• 27 cases • 3 cases
• 4 PVE • 0 PVE
• 3 two-stage • 0 two-stage
hepatectomy hepatectomy
 Patient Characteristic

Clinical Variables Value

Age, median (range), y 48 (38-71)
Male/female, No. (%) 17/10 (63%/37%)
Hepatitis B surface antigen positive, No. (%) 14 (37.50)
Serum α-fetoprotein, median (range), ng/ml 268 (42-1000)
Serum albumin, median (range), g/dl 3,2 (2,8-4,3)
Serum aspartate aminotransferase, median (range), U/L 36 (21-108)
Serum alanine aminotransferase, median (range), U/L 29 (11-89)
Hemoglobin, median (range), mg/dL 11,2 (10,4-13,8)
Child-Pugh grade, median (range), %
A 15 (55.6%)
B 12 (44.6%)
 Extent of Major Liver Resection

Type of resection Number Percentage (%)

1. RIGHT

- Posterior sectionectomy 5 18.5 %

- Anterior sectionectomy - -
- Hepatectomy 5 18.5%
- Trisectionectomy 4 14.9%
2. LEFT

- Lateral sectionectomy 3 11.1%

- Hepatectomy 4 14.9%
- Segmentectomies 6 22.2%
TOTAL 27 100.00
 Operative Data
Blood Loss Number (n=27) Percentage (%)

- < 250 ml 6 22.2

- 250 – 750 ml 5 18.5
- 750 – 1500 ml 10 37
- >1500 ml 6 22.2
Pringle’s manuever
- Selective 20 74
- Non Selective 2 7.4
- No 5 18.5
Operation Time
- < 2 hours 2 7.4
- 2-4 hours 11 40.7
- >4 hours 14 51.9
Intra Operative US
- Yes 17 63
- No 10 37
Fibrin glue
- Yes 15 55.6
- No 12 44.4
Type of Incision
- Right -J Abdominal 15 55.6
- Right -J Thoraco-Abdominal 3 11.1
- Left-J Abdominal 3 11.1
- ‘Mercedez’ 6 22.2
 PERI-OPERATIVE DEATH (n=6; 22.2%)

CASE 1 CASE 2 CASE 3 CASE 4 CASE 5 CASE 6

Causes Massive Hepatic Sepsis Sepsis Massive Massive

re- failure bleeding bleeding
bleeding
Day 2 16 28 11 2 1

Resection R- R- R-Anterior R-Anterior R R

Trisectone Trisectionect Sectionecto Sectionectomy Hepatectomy Hepatectomy
ctomy omy my
Blood Loss 1100 ml 1800 ml 1200 ml 2000 ml >2000 ml >2000 ml
Age 55 44 66 61 58 63
Op Time 280 mnts 320 mnts 200 mnts 200 mnts 280 mnts 280 mnts
Blood 2000 cc 1000 cc 500 cc 1500 cc 2000 cc 2000 cc
Transfusion
PVE Yes Yes No No No No
 PORTAL VEIN EMBOLIZATION

Case 1 Case 2 Case 3 Case 4

FLRV (%)
- pre-PVE 38.6% 35.8% 44.8% 48.5%
- post-PVE 46.2% 44.1% 46.4% 51.0%
Parenchyma Non- Non-Cirrhosis Cirrhosis Cirrhosis
Cirrhosis
R-Trisectorectomy Yes Yes Yes Yes

Waiting (weeks) 4 4 5 5
Tumor size (cm) 18 22 16 18
Intraoperative bleeding 1300 1050 1800 800
(ml)
Operation time (minutes) 400 380 360 290
Thank you for your attention