Consider the venous outflow as well as the liver inflow during staged hepatic resections

Here is my highlight from this months (November) HPB Journal published by Wiley. (In terms of conflict of interest I should state that I am one of 3 Associate Editors of this Journal).

The success of chemotherapy for colorectal hepatic metastases and the improvements in technique and anaesthesia, which have lead to improved safety in liver surgery, have meant that more patients can have the opportunity to undergo liver resection. Staged liver resection is defined as a planned procedure where part of the liver is removed and regeneration of the liver remnant is allowed to occur before a second surgery to remove residual tumour is performed.

This type of surgery can be difficult for a number of reasons not least it demands that regeneration of the liver remnant will occur to allow the second procedure to take place safely. Chemotherapy induced sinusoidal obstruction syndrome, steatosis and fibrosis can all limit this regeneration. In surgical terms most of the attention in staged resection has concerned the hepatic inflow as a regulator of liver regeneration. In this issue of HPB, Faitot et al , explore the influence of venous congestion and venous drainage as a determinant of regenerative capacity.

They studied patients who underwent a right hepatectomy in whom the middle hepatic vein tributaries to segment IV were removed or not. They demonstrated that preservation of the tributaries of segment IV draining into the middle hepatic vein permitted greater regeneration of segment IV after right hepatectomy than in patients where these tributaries were sacrificed.

Planning staged resections is never easy, but this study highlights the importance of giving serious consideration to the venous drainage of the future liver remnant to ensure maximum regeneration and thereby improve ease and safety of subsequent liver resection.

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