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Is Combined Partial Hepatectomy With Segmental Resection of Inferior Vena Cava Justified for Malignancy?
Juan M. Sarmiento, MD;
Thomas C. Bower, MD;
Kenneth J. Cherry, MD;
Michael B. Farnell, MD;
David M. Nagorney, MD
Arch Surg. 2003;138:624-631.
Hypothesis En bloc partial hepatectomy with inferior vena cava (IVC) resection may be the only curative strategy for patients with hepatic malignancies involving the IVC.
Design Retrospective study.
Setting Tertiary referral center.
Patients All consecutive patients undergoing combined partial hepatectomy with segmental IVC resection and reconstruction between 1990 and 2002. Patients with tangential excision of the IVC were excluded. Follow-up was completed by outpatient clinic visits and mail correspondence.
Main Outcome Measures Perioperative outcomes; overall and recurrence-free survival.
Results Nineteen patients (7 men and 12 women) underwent partial hepatectomy and segmental IVC resection and reconstruction. Median age was 59 years (range, 24-74 years). Diagnoses consisted of cholangiocarcinoma (9 patients), metastatic tumor (5 patients), sarcoma (3 patients), and hepatocellular carcinoma (2 patients). Major hepatectomies ( 3 segments) were performed in 15 patients; the caudate lobe was resected in 13. Hepatic vascular isolation was used in 13 patients. Ringed polytef grafts were used for IVC reconstruction in all but 1 patient. Transfusion was necessary in 18 patients (median requirement, 5 U). Median operative time was 6.3 hours (range, 3.7-9.0 hours), and hospitalization was 10.5 days (range, 6-41 days). Negative margins of resection were achieved in 16 patients. Complications occurred in 8 patients (42%), including 1 perioperative death (5%). There was evidence of mural thrombosis of the graft in 2 patients (both nonocclusive); warfarin sodium was used postoperatively in 14. Late graft thrombosis was evident in 2 patients. Median overall survival was 38 months (5-year survival, 21%), and recurrence-free survival was 11.5 months (5-year survival, 0%).
Conclusions Patients with large tumors involving both the liver and the IVC are candidates for partial hepa-tectomy and segmental IVC resection. Resection affords the possibility of negative margins, acceptable perioperative morbidity and mortality, long-term graft patency, and prolonged survival.
From the Divisions of Gastroenterologic and General Surgery (Drs Sarmiento, Farnell, and Nagorney) and Vascular Surgery (Drs Bower and Cherry), Mayo Clinic and Mayo Foundation, Rochester, Minn.
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