Langenbecks Arch Surg (2009) 394:1057–1063 DOI 10.1007/s00423-009-0554-0
ORIGINAL ARTICLE
Caudate lobe resection: an Egyptian center experience Mohamed Abdel Wahab & Abdul Razzak Oluwagbemiga Lawal & Ehab EL Hanafy & Tarek Salah & Emad Hamdy & Ahmad M. Sultan
Received: 17 April 2009 / Accepted: 20 August 2009 / Published online: 9 September 2009 # Springer-Verlag 2009
Abstract Summary background data Hepatectomy is a technically challenging surgery, and of all aspects of hepatic resection, caudate lobe resection is the most difficult. Knowledge of the anatomy of the caudate lobe is necessary to achieve safe caudate lobe resection. Methodology Hospital records of 54 patients, who had caudate lobe resection in our center from January 2000 to August 2007, were retrieved. The demographic data, clinicopathological features, and perioperative events were extracted and analyzed. Results Out of a total of 500 patients who had various forms of hepatic resection during the period in question, only 54 had caudate lobe resection (10.8%). Isolated caudate lobe resection (ICLR) was performed in 16 (29.6%) patients while the remainder had caudate lobe resection as a part of a major hepatectomy. Indications for hepatectomy in patients with ICLR include hepatocellular carcinoma, primary hepatic carcinoid tumor, cavernous hemangioma, and adenoma. Mean operative time for ICLR was 230±50 min while it was 240±50 min for right hepatectomy and 245±55 min for left hepatectomy. The associated mean blood loss was 1200±200, 1300±350, and 1350±350 ml, respectively. None of these were statistically significant. In patients who had ICLR, there was no mortality while three patients developed postoperative complications (bile leak in two patients and one patient with wound infection). Various forms of perioperative M. A. Wahab (*) : A. R. O. Lawal : E. EL Hanafy : T. Salah : E. Hamdy : A. M. Sultan Gastroenterology Surgical Center, Jehan Street, Mansoura University, Mansoura, Egypt 35116 e-mail:
[email protected]
complications were noticed in six patients. All these patients, who also showed 7.8% mortality, had major hepatectomy. Conclusions Caudate lobe resection is a technically challenging procedure. Isolated caudate lobe resection is a safe procedure with good outcome in well selected patients. It is, however, associated with increased perioperative risks when associated with major hepatectomy. Keywords Caudate lobe . Hepatectomy . Perioperative complications Abbreviations ICLR Isolated caudate lobe resection HCC Hepatocellular carcinoma PHCT Primary hepatic carcinoid tumor
Introduction The caudate lobe is traditionally divided into three parts: the Spiegel lobe, paracaval portion, and caudate process. It is located anterior to the inferior vena cava (IVC) and may envelop it circumferentially [1]. The caudate lobe can be the origin of primary liver tumors or the sole site of metastases to the liver. More commonly, the caudate lobe is involved by extension from tumors in other liver segments. Although wedge or partial resection of the caudate lobe is often possible, it is less controlled and may be more dangerous than complete caudate lobectomy. Inadequate tumor clearance is also a major concern [2]. In addition, hilar cholangiocarcinoma (hilar CC) at the confluence of the bile duct frequently involves caudate bile
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ducts and may also extend to the caudate lobe. Resection of the caudate lobe of the liver is thus often necessary for complete clearance of tumor during hepatic resection; the procedure may be required as isolated lobe resection or as caudate resection combined with major hepatectomy [3]. Resection of the caudate lobe has been used infrequently in the past, partly because of the difficulty of dissection and partly because of a perception of early involvement of the IVC or portal vein by tumors. Precise anatomical knowledge of the caudate segment, improvements in preoperative care, and recent descriptions of surgical technique for caudate lobectomy have resulted in more widespread use of this procedure [4].
Patients and methods The medical records of all patients who had hepatic resection at the Gastroenterology Surgical Center of Mansoura University between January 2000 and August 2007, were retrieved. Five hundred patients had various forms of hepatic resection while only 54 patients had hepatic resection involving the caudate lobe either a part of major hepatectomy (MH) or isolated caudate lobe resection (ICLR). The demographic data, preoperative clinical features, perioperative events, and postoperative data of these patients were retrieved and analyzed. All patients were subjected to clinical assessment (including surgical fitness), laboratory investigations (including complete liver function and virology), and radiological study (including ultrasonography and triphasic CT scan) to evaluate the extent of the tumor, vascular involvement, lymph node affection, and hepatic lobes size (Fig. 1). In patients with hilar CC, magnetic resonance cholangiopancreatography was done in all cases while preoperative decompression of the biliary system was performed as indicated. Surgical technique for ICLR (Fig. 2) We usually approach the caudate lobe through a bilateral subcostal incision. The central venous pressure (CVP) is maintained at 5 mmHg, and the patient was usually placed in a 15-degree anti-Trendelenburg position. The entire liver is examined by intraoperative ultrasonography. Cholecystectomy is performed only for specific pathology. The caudate lobe may be approached from the left or right depending on the assessment of the lesion and the procedure to be performed. The dissection starts by opening the gastrohepatic ligament. The ligamentum venosum is transected at the root of the left hepatic vein, which is facilitated by lifting the left lateral segment anteriorly. Peritoneum and fibrous attachments between caudate lobe
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and the left side of the IVC are divided to gain access to the posterior face of the caudate lobe. Typically, we do not fully mobilize the liver before the dissection of the caudate lobe is started. However, for large tumors, full mobilization is indicated. The fibrous retrocaval ligament joining the caudate lobe on the left side of the IVC and segment VII of the liver is divided. This maneuver is extremely important in fully mobilizing the caudate lobe to expose the hepatic veins along the anterior surface of the IVC. Once the left lateral edge of the caudate lobe is free, this portion is lifted off the IVC, and subsequent ligation of the retrocaudate veins draining directly into IVC is performed. Usually, 1 to 3 sizable veins (3–8 mm) are encountered; the largest vein usually enters the IVC anteriorly. Most of the outflow of the caudate lobe can be controlled in this step. Occasionally, dissection to the side of the portal triad is necessary to divide the hepatic veins from the caudate process. After this step, the caudate lobe is fairly mobile and can be grasped with the left hand of the surgeon which gave an access to ligate and divide the portal vein branch to caudate lobe. Parenchymal transaction can be initiated along the right margin of the caudate lobe using harmonic scalpel and progress superiorly. We do not routinely use Pringle’s maneuver or hepatic vascular isolation. Any bleeding from the major hepatic veins anteriorly is suture-ligated with fine monofilament suture.
Results There was a total of 54 patients who required caudate lobe hepatectomy during the period of the study. There were 33 male and 21 female patients. Table 1 shows the most common indication for caudate lobe resection and other preoperative laboratory data. Isolated caudate lobectomy was performed in 16 patients while major hepatectomy was performed in the remainder. Age range was 35 to 65 years (mean 50±11 years). The most common indications for ICLR were: hepatocellular carcinoma (HCC; Fig. 3), cavernous hemangiona (Fig. 4), primary hepatic carcinoid tumor (PHCT), and hepatic adenoma. The procedures performed for the patients with the various diagnoses are as presented in Table 2. In patients with hilar CC, we do segment IVb resection in addition to right hepatectomy. All the patients with ICLR were presented by right hypochondrial pain in addition to weight loss in HCC and PHCT. One patient with giant hemangioma was presented by bilateral pedal edema of lower limbs. All these patients had normal liver functions. Hepatitis C antibody was positive in five patients while hepatitis B was negative for them. All patients with HCC have liver cirrhosis; patients with benign liver lesions have normal liver while some
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Fig. 1 CT show different types of caudate lobe tumors
(A) Haemangioma before resection
(B) Post resection
Adenoma
HCC
Carcinoid tumor patients with hilar CC have mild liver cirrhosis due to high prevalence of hepatitis C virus infection in our country. The mean operative time for patients with ICLR was 230±50 min while intraoperative blood loss was 1200± 200 ml. There was no significant difference in the mean operative times between patients who had ICLR and patients who had MH (240±50 min for right hepatectomy and 245±55 min for left hepatectomy). There was also no significant difference in the intraoperative blood loss of the patients (Table 3). The three patients who had ICLR developed three postoperative complications. Two patients developed bile leak which managed conservatively; one patient developed
wound infection. There was no postoperative mortality. The mean length of hospital stay after operation was 12±7 days. However, various forms of perioperative complications were noticed in six patients with 11 postoperative complications. All these patients had major hepatectomy. This is shown in Table 4.
Discussion The caudate lobe resection has traditionally been viewed as the forbidding and difficult aspect of liver surgery [2]. This is due to the unique anatomical relationship of the caudate
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Dissection of peritoneum between IVC and caudate lobe from left side
Right side dissection from IVC
Arrow : caudate Adenoma
Arrow : caudate HCC
2
Posterior dissection of caudate lobe from IVC
1
Left hepatectomy plus caudate lobectomy (1 ) IVC ( 2) Middle hepatic vein
Fig. 2 Operative photos show different techniques of caudate lobe resection
lobe to the portal vein and inferior vena cava. Also, because of the fact that it is straddled by the two major lobes of the liver, isolated caudate lobe resection is more technically challenging than caudate lobe resection as part of a major hepatectomy. One of the earliest reports of isolated caudate lobe resection was by Glotzer et al. [3], though it was not on account of a caudate lobe tumor. The first report of a successful caudate lobe resection for tumor was by Lerut et
al. [4]. Early reports of caudate lobe resection required some form of resection of other hepatic segments for technical reasons [5]. The most common indication for caudate lobe resection in most series was either colorectal cancer metastasis [1,6,7] or cholangiocarcinoma [8]. Our series also has hilar CC as the most frequent indication. However, we found hepatocellular carcinoma to be the most common indication for ICLR in our series, the same
Table 1 Indication and preoperative laboratory data Pathology Hilar CC HCC PHCT Hemangiomas Adenoma
Number
Album. (g/dl)
Bil. (mg/dl)
AP KAU
Proth. (%)
+ve HCV Ab No
+ve HBsAG No
Cirrhosis
32 12 5 3 2
4.3 4.5 4.5 4.6 4.4
16.5 0.8 0.7 0.8 0.9
45 12 6 10 11
75 88 99 95 90
9 5 1 1 0
0 0 0 0 0
13 12 0 0 0
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2
1 Fig. 3 Operative photos show dissection of caudate tumor from IVC with ligation and division of feeding vessels. (1) IVC (2) Posterior hepatic vein
as the series by Fan et al. [9] while hemangiomas were the most common indications for ICLR in a series of 24 patients by Popescu et al. [10]. It is pertinent to note that there was no case of colorectal secondary in our series. The explanation for these differences may be geographical. They may also be explained by the high prevalence of hepatitis C virus and liver cirrhosis in our environment: a cirrhotic liver is not a good milieu for metastatic carcinoma. Our experience in Mansoura has been that only a negligible percentage of patients with colorectal carcinoma in our environment develop hepatic metastasis. There are three ways to approach and resect the caudate lobe of the liver, an isolated caudate lobectomy, a combined resection of the liver in continuity with the caudate lobe, and a transhepatic anterior approach by splitting parenchyma of the liver [11,12]. The approach to the caudate lobe depends on the location of the tumor and the expertise of the surgeon. That
Fig. 4 Operative photos show large caudate hemangioma. a Huge exophytic hemangioma from the caudate lobe of the liver. b After complete inoculation of the hemangioma. c Operative specimen shows the two parts of the hemangioma: caudate process (A) and caudate proper (B)
A
B A - Huge hemangioma exophytic from the caudate lobe of the liver B - After complete inoculation of the hemangioma
A C - Operative specimen shows the 2 parts of the haemangioma
(caudate proses A & Caudate proper B)
B
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Table 2 Procedures performed for various diagnoses Pathology
Number Rt hepatectomy +ve CLR
Hilar CC HCC PHCT Hemangiomas Adenoma Total number Percentage
32 12 5 3 2 54 100
10 2 2 0 0 14 26
Lt hepatectomy +ve CLR 22 2 0 0 0 24 44.4
Isolated caudate lobectomy 0 8 3 3 2 16 29.6
new approaches are still being devised to the caudate lobe is a testimony to the fact there is no approach that is superior to the other [11–15]. In our series, our approach to the caudate lobe was based on the location of the tumor. There was no hard and fast rule. While some tumors were approached from the right, others were approached from the left while a combined approached was employed in some patients as dictated by the intraoperative findings. However, we did not perform an anterior approach in any of these patients. Liver surgery is a very bloody procedure. However, the prevention of excessive primary hemorrhage in caudate lobe resection deserves special mention. This is so because of the unique anatomical relationship of the caudate lobe to the inferior vena cava and the portal vein. Because the caudate lobe drains directly into the inferior vena cava and these veins are very short, care must be taken when dividing them. Most authors recommend vascular control during caudate lobe resection. Most authors agree on the need to lower the CVP to 5 mmHg and positioning the patient at 15-degree anti-Trendelenburg. However, the need for vascular control in the form of intermittent clamping and release of the portal vessels or complete vascular control has its proponents and opponents. Vascular control may be combined with positioning and CVP control to minimize intraoperative blood loss. Most of our patients with benign conditions did not require vascular control while the use of either total or intermittent vascular control was employed in the surgery for malignant
conditions of the caudate lobe. It is worthy of note that one of our patients who had a 4.8-kg caudate lobe hemangioma did not require blood transfusion in spite of the enucleation of his hemangioma being performed without vascular control. There was no significant difference in blood loss between patients with ICLR and MH; this might be due to our large experience in liver surgery with various forms of hepatectomies, and so, it is easier to do combined hepatectomy with caudate lobe resection over ICLR only. Early reports of caudate lobectomy were associated with mixed results with some authors reporting significant [16] and others, minimal postoperative complications [16]. The common complications of caudate lobe resection include postoperative bile leak, which may lead to infectious complications if not properly managed. Total caudate lobectomy was identified as an independent predictor of the development of postoperative bile leakage [17]. Another complication is hepatocellular failure which usually depends on the extent of the surgical procedure. It is rare with ICLR but is found in patients with poor functional reserve subjected to major hepatectomy. Due to the fact that there was no significant difference in postoperative survival rate between patients who underwent limited resection of the caudate lobe and those who underwent extended caudate lobectomy, some tend to recommend limited resections for tumors of the caudate lobe [18]. Hepatic failure is also more prevalent in patients with underlying liver cirrhosis. Ascites, pleural effusion, atelectasis, and multisystem organ failure may also complicate it. Though some authors have reported that the addition of caudate lobectomy to major liver resection does not add significantly to the morbidity or mortality of the procedure [7], this was not so in our series as the addition of major liver resection was associated with increased morbidity. This difference in outcome can, however, be explained by the differences in case mix. Most of our patients who had major liver resection had cholangiocarcinoma, which, in itself, was associated with increased surgical risk in contrast to metastatic colorectal cancer and hepatocellular cancer. In a report of six patients with HCC originating from the caudate lobe, there was no operative mortality or major Table 4 Postoperative complications
Table 3 Operative results according to type of resection Type of resection
Number
Operative time (min)
Blood loss (ml)
Rt hepatectomy Lt hepatectomy
14 24
240±50 245±55
1300±350 1350±350
Isolated resection Total results
16 54
230±50 240±50
1200±200 1300±350
Morbidity Bile leak Wound infection Liver cell failure Mortality
Major hepatectomy (n=38)
Isolated resection (n=16)
6 (15.7%) 5 3 3 7.8%
3 (18.7%) 2 1 – 0%
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operative morbidity [19]. While in another report of 30 patients with hepatocellular carcinoma, caudate lobectomy was found to be safe with favorable outcomes [16]. Conclusion In our experience, caudate lobe resection is a technically challenging procedure. It is, however, a necessary part of the hepatic surgeon’s armamentarium in the care of patients with hepatobiliary tumors. Isolated caudate lobe resection is a safe procedure with good outcome in well selected patients. It is, however, associated with increased perioperative risks when combined with major hepatectomy.
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