Hepatic Resection for Primary or Secondary Malignancies with Involvement of the Inferior Vena Cava: Is This Operation Safe or Hazardous? Bruno Nardo, MD, PhD, Giorgio Ercolani, MD, Roberto Montalti, MD, Riccardo Bertelli, MD, Andrea Gardini, MD, Paolo Beltempo, MD, Lorenza Puviani, MD, Vincenzo Pacilè, MD, Marco Vivarelli, MD, Antonino Cavallari, MD This study evaluated surgical techniques and results of patients with tumors who had undergone liver resection with partial resection and reconstruction of the IVC. STUDY DESIGN: We performed a retrospective analysis of all patients who underwent combined liver and IVC resection and reconstruction at a single institution. We identified 19 patients and two categories of tumors, primary (n ⫽ 8) and metastatic (n ⫽ 11). In 12 patients, a direct suture of the IVC was performed; in 3 patients a pericardium bovine patch was applied; in another 4 patients the IVC was replaced by PTFEt prosthesis. In nine patients, total hepatic vascular occlusion was required. RESULTS: Perioperative mortality was 5.9%, related to technical complications and hepatic insufficiency. Postoperative morbidity was 57.9%. Median survival time was 32 months (range 3 to 125 months). The 1-, 2-, and 5-year cumulative survival rates were 78.9%, 68%, and 49.1%, respectively. Tumor recurrence appeared in 13 patients and was the main cause of death (55.5%). Among the seven patients suffering from hepatocellular carcinoma, three are still alive at 31, 60, and 125 months after resection. In this group, 1-, 2-, and 5-year survival rates were 71.4%, 57.1%, and 38.1%. Among the 11 patients resected for colorectal liver metastases, the 1-, 2-, and 5-year survival rates were 81.8%, 62.3%, and 51.9%, respectively. CONCLUSIONS: Liver resection combined with IVC resection and reconstruction is a feasible procedure that can be performed with an acceptable operative risk leading to longterm outcome in selected patients. (J Am Coll Surg 2005;201:671–679. © 2005 by the American College of Surgeons) BACKGROUND:
tumors operable. In the last 10 years, several authors have reported aggressive surgical resections of liver tumors infiltrating the IVC with different kinds of IVC repair, using direct suture or replacement by autogenous vein or prosthetic material graft.1,2,4,8-13 All these studies are case reports or in series that include small numbers. No clear guidelines exist about the best way to reconstruct the IVC and there is no definite consensus about late results after such aggressive operations. The aim of this study was to review our experience with liver resection and IVC resection and reconstruction and analyze the type of IVC repairs, postoperative morbidity, mortality, and longterm outcomes.
Tumor invasion of the IVC can occur in primary or metastatic hepatic malignancies mainly located in the caudate lobe or in posterior segments.1,2 Frequently, the IVC can be infiltrated by tumors originating in the kidney or adrenal gland or retroperitoneal soft tissue.3,4 Patients with hepatic tumors involving the IVC have usually been considered unresectable, with very poor outcomes. Recent advances in surgical techniques and experience in liver transplantation5-7 have made these Competing Interests Declared: None. Received May 12, 2005; Revised June 23, 2005; Accepted June 29, 2005. From the General Surgery Unit, Department of Surgery, Intensive Care Unit and Transplantations, S Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. Correspondence address: Bruno Nardo, MD, PhD, Department of Surgery, Intensive Care Unit and Transplantation, S Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy.
© 2005 by the American College of Surgeons Published by Elsevier Inc.
METHODS From November 1985 to December 2002, there were 830 consecutive liver resections for hepatic primary (n
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Table 1. Pathological Characteristics, Surgical Procedure, and Outcomes of Patients with Primary Hepatic Tumors and IVC Involvement Age (y)
Diagnosis
Nodules Diameter n (cm)
51 HCC
1
14
61 72 51 31
1 1 1 1
2.2 7 13 14.7
HCC on cirrhosis HCC HCC on cirrhosis HCC
59 HCC 1 41 HCC 1 74 Cholangiocarcinoma 1
10 11 13
Type of liver resection
Extended right hepatectomy S1 resection S6 S7 resection Right hepatectomy Right hepatectomy
Concomitant procedures
None
None None Diaphragm resection Right nephrectomy/ adrenalectomy Right hepatectomy Diaphragm resection Right hepatectomy Diaphragm resection Extended right Right adrenalectomy hepatectomy
IVC repair
Outcomes Histologic invasion Vascular Survival of IVC control Recurrence (mo)
PBP
Yes
THVE
Yes
26 (alive)
Direct suture Direct suture Direct suture PBP
Yes Yes Yes Yes
LC IHPCLC IHPCLC IHPCLC
No No Yes Yes
36 (died) 60 (alive) 5 (died) 31 (alive)
Direct suture PTFEt Direct suture
Yes Yes Yes
THVE THVE LC
No Yes Yes
9 (died) 25 (died) 60 (alive)
HCC, hepatocarcinoma; IHPC, intermittent hepatic pedicle clamping; LC, lateral clamping; PBP, pericardium bovine patch; PTFEt, polytetrafluoroethylene tube; THVE, total hepatic vascular exclusion.
⫽ 462) or metastatic malignancies (n ⫽ 368) performed at the Department of Surgery and Transplantation, University of Bologna. A retrospective analysis was performed of 19 patients (2.3%) who underwent combined liver and IVC resection with primary or patch closure and those who had graft replacement. This group represents the study population of the present report, with followup ending on March 31, 2003. Reason for surgical resection was primary hepatic tumor in 8 patients (1.7%) and secondary hepatic tumor in the remaining 11 (2.9%). In the first group, there were seven patients with hepatocellular carcinoma (two of them cirrhosis), and one patient with cholangiocarcinoma. In the second group, there were 11 patients with metastases from colorectal carcinoma; 8 of these received adjuvant postoperative chemotherapy without any type of randomization. In particular, we investigated preoperative patient status, tumor type and localization, extent of IVC resection, and early and late followup with regard to recurrence and survival. Pathologic characteristics, operative procedure, and outcomes of patients with primary or secondary hepatic tumors and IVC involvement are reported in Tables 1 and 2, respectively. There were 14 (73.7%) men and 5 (26.3%) women. Mean ⫾ SD age was 55.1 ⫾ 11.8 years (range 31 to 74 years). Type of procedure was defined according to the Couinaud’s classification of liver segments.14 Resection of three or more segments was defined as a major hepatectomy. Preoperative assessment
Preoperative diagnostic workup included evaluation of liver function, measurement of ␣-fetoprotein or CEA
level, chest x-ray film, hepatic ultrasonography, and abdominal spiral CT scan. MRI was performed in four patients and cavography in two patients in whom IVC involvement was suspected. Preoperative radiologic assessment was performed to clarify the localization and number of tumors, the relationship with the main hepatic veins and the hilar structures, and presence of IVC invasion. From the preoperative assessment, involvement of the IVC was diagnosed in 11 patients (57.9%), 4 with primary and 7 with secondary tumors, and in 6 patients (42.1%) (2 with primary and 4 with metastases) it was an intraoperative finding by surgical exploration and ultrasonography. No patient had extrahepatic distant metastases or local recurrence at the time of liver resection. An extensive medical evaluation of all patients was performed to assess operative risk. Surgical approach
A right subcostal laparotomy with upper midline extension to the xyphoid process was performed in all patients. A mechanical retractor was used (Kent Retractor; Takasago Medical Industry Co Ltd.). Intraoperative ultrasonography was used in all patients, leading to detection of a partial infiltration of the IVC wall in six patients (42.1%), which was not discovered during the preoperative evaluation. Intraoperative ultrasonography was useful to verify tumor extension and degree of neoplastic infiltration of the IVC and to study the relationship with the hepatic veins and intrahepatic portal pedicle.1,7,13 No additional hepatic lesions were detected by this procedure compared with preoperative evaluation.
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Table 2. Pathological Characteristics, Surgical Procedure, and Outcomes of Patients with Secondary Hepatic Tumors and IVC Involvement Age (y)
Nodules
Primary site of cancer
n
Size (cm)
54
Colorectal
1
3
72
Colorectal
1
7.5
60
Colorectal
4
4
47
Colorectal
3
5
63
Colorectal
3
3.2
50
Colorectal
2
4
46
Colorectal
1
13
65
Colorectal
1
4
40
Colorectal
2
6
64
Colorectal
4
4
47
Colorectal
2
3
Type of liver resection
Extended left hepatectomy Extended right hepatectomy Extended left hepatectomy Extended right hepatectomy Extended left hepatectomy Extended left hepatectomy Right hepatectomy Extended right hepatectomy Extended right hepatectomy Left hepatectomy S7 resection
IVC repair
Histologic invasion of IVC
Recurrence
Survival
None
Direct suture
No
THVE
Yes
89 (alive)
None
Direct suture
Yes
THVE
No
2 (died)
None
Direct suture
No
THVE
Yes
42 (alive)
None
Direct suture
Yes
IHPC/LC
Yes
36 (alive)
None
Direct suture
No
IHPC/LC
Yes
35 (alive)
None
PBP
No
THVE
Yes
45 (alive)
None
PTFEt
Yes
THVE
Yes
22 (died)
None
PTFEt
Yes
THVE
No
0 (died)
Diaphragm resection None
PTFEt
Yes
Yes
32 (died)
Direct suture
No
IVC clamp IHPC
No
19 (alive)
Diaphragm resection
Direct suture
No
IHPC
Yes
13 (died)
Concomitant procedures
Vascular control
HCC, hepatocarcinoma; IHPC, intermittent hepatic pedicle clamping; LC, lateral clamping; PBP, pericardium bovine patch; PTFEt, polytetrafluoroethylene tube; THVE, total hepatic vascular exclusion.
The 19 hepatic resections with IVC resection and reconstruction consisted of 6 (31.5%) extended right hepatectomies, 5 (26.3%) right hepatectomies, 4 (21%) extended left hepatectomies, 1 (5.2%) left hepatectomy, 3 (15.7%) segmentectomies: caudate lobe,1 resections of segments 6 and 7,1 and segment 71. In all patients, the hepatic parenchyma was transected using the standard Kellyclasia.7 In nine (47.4%) patients a total hepatic vascular exclusion (THVE) was performed (in two patients with hepatocellular carcinoma and seven with metastases). It was well tolerated in all patients without need for systemic veno⫺venous bypass. Mean time of THVE was 33.9 minutes (range 14 to 69 minutes). In the other 10 patients, a cross-lateral clamping of the IVC was applied. Briefly, in the presence of a tumor of the right lobe infiltrating the vena cava (n ⫽ 5), THVE was begun after resection had passed the hilar plane, as for a conventional right hepatectomy. A De Bakey clamp was first placed on the subhepatic vena cava, followed by a clamp on the hepatic pedicle and finally a clamp on the suprahepatic vena cava (Fig. 1A). As dissection continued upwards, the right hepatic vein was identified. The
anterior aspect of the IVC was then gradually freed and divided below the confluence with the middle and left hepatic vein. Resection of the inferior vena cava was performed immediately below the liver and the right liver was removed en bloc with the tumor and with the entire segment of the infiltrated vena cava. In three patients who underwent THVE, because there was enough space between the trunk of the hepatic veins and the upper limit of the vena cava infiltration, another vascular clamp was placed on the vena cava immediately below the trunk of the hepatic vein so that the suprahepatic caval clamp and the Glissonian pedicle clamp could be opened, ending vascular exclusion of the liver. Only the vena cava remained clamped and the vascular exclusion of the liver was then limited to 14 to 20 minutes. If, on the other hand, there was no adequate safety margin for a second caval clamp below the confluence of the hepatic veins, the first part of caval reconstruction was continued with THVE (Fig. 1B) and the caval clamp was moved onto the prosthesis after proximal caval anastomosis had been completed (Fig. 1C).
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IVC reconstruction
In 12 patients (63.2%), direct suturing was performed to repair the IVC, the vessel wall being involved for a mean length of 1.4 cm (range 1 to 2 cm). In three patients (15.8%), where length of IVC involvement was between 5 and 7 cm, a bovine pericardium patch was applied to repair the IVC. Finally, in the remaining four patients (21.1%), retrohepatic IVC totally involved by the tumor was replaced with a PTFEt prosthesis of 14 mm in diameter (1 patient), 16 mm (1 patient), and 18 mm (2 patients). Replacement was performed under THVE in three patients and under TIVC clamping in one patient. In all patients the first two rings of the armed Gore-Tex (WL Gore & Assoc) prosthesis were removed to make the anastomosis softer. In all patients, a proximal anastomosis was fashioned below the middle and left hepatic vein. We never had to resort to hypothermic lavage of the liver or use of venous bypass. Anticoagulant therapy
Within 24 to 48 hours after the operation, all patients received a low dose of subcutaneous heparin. Warfarin (dicoumarin) was administered po at the beginning of oral intake, only in patients with a PTFEt prosthesis (n ⫽ 4) and a bovine pericardium patch (n ⫽ 3), modifying the dosage to maintain the international normalized ratio index between 2.0 and 3.0; warfarin was taken indefinitely by these patients if there were no side effects. Graft patency and recurrence
Graft patency was evaluated in the short- and longterm period by radiologic assessment including ultrasonography, CT, MRI and, in one patient, cavography. The same radiologic imaging procedures were used to assess tumor recurrence or distant metastases. Statistical analysis
Results are expressed as mean ⫾ SD. Differences between groups of primary and metastatic tumors were evaluated with Student’s t-test or the chi-square test with
Figure 1. (A) Total hepatic vascular exclusion (THVE) before the end of right hepatectomy for a tumor also infiltrating the IVC. (B) At the end of the hepatectomy with total resection of the IVC, a proximal anastomosis is fashioned with the PTFEt prosthesis under THVE. (C) At the end of the proximal anastomosis with the PTFE prosthesis, the suprahepatic clamp is removed and replaced on the prosthesis, and the hilar clamp is removed to reperfuse the left liver. Distal caval anastomosis is completed.
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Yates’ correction for continuity or Fisher’s exact test when appropriate. Postoperative survival was computed from the day of resection to last followup or date of death. Survival rates were estimated by means of the life-table method and differences between survivals compared with the logrank test. Survival rate was calculated using KaplanMeier method. Data were managed with use of SPSS software package 10.0 (SPSS, Inc.) and p ⬍ 0.05 was considered statistically significant. RESULTS Early outcomes
Mean ⫾ SD amount of intraoperative red blood cells was 900 ⫾ 670 mL (range 0 to 3,000 mL). Mean ⫾ SD amount of intraoperative fresh frozen plasma was 1,000 ⫾ 800 mL (range 800 to 3,000 mL). In four patients (21.1%) there was no need for red blood cell transfusion. Perioperative mortality was 5.9%. Only one patient died, on the third postoperative day of hepatic insufficiency after right hepatectomy extended to the caudate lobe for metastasis from colorectal cancer, with a THVE exceeding 60 minutes. No difference was found in operative mortality according to type of vascular control or type of IVC reconstruction. Postoperative complications appeared in 11 patients (57.9%). Pleural effusion was the most frequent (six patients), followed by postoperative transient liver failure, which consisted of a rise in transaminases and total bilirubin levels associated with mild ascites for up to 15 days (three patients). Relaparotomy was required in one case of subphrenic abscess not controlled by percutaneous approach. Resection margins always proved to be tumor-free at histologic examination. Mean hospital stay ⫾ SD was 17.6 ⫾ 6 days (range 7 to 37 days). Longterm outcomes
Median survival time was 32 months (range 3 to 125 months). The 1-, 2-, and 5-year cumulative survival was 78.9%, 68%, and 49.1%, respectively. Nine patients died during followup and 10 patients are still alive. Tumor recurrence appeared in 13 patients (68.4%) and was the main cause of death in 5 (55.5%). The most frequent recurrence was intrahepatic, followed by lung metastases. In four patients (30.7%) patients, a second liver resection was possible. Three of them are still alive without evidence of recurrence. In the other patients, pallia-
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tive chemotherapy was administered. Among the seven patients suffering from hepatocellular carcinoma, three are still alive at 31, 60, and 125 months after resection. In this group, 1-, 2-, and 5-year survival rates were 71.4%, 57.%, and 38.1%. Tumor recurrence appeared in four patients. The patient with cholangiocarcinoma is still alive with intrahepatic recurrence 60 months after the operation. Among the 11 patients resected for colorectal liver metastases, 1-, 2-, and 5-year survival rates were 81.8%, 62.3%, and 51.9%, respectively. Tumor recurrence appeared in eight patients. Six patients are still alive at 19, 35, 36, 42, 45, and 89 months after operation. Precise outcomes for each patient are reported in Tables 1 and 2. In all patients, IVC patency was confirmed by routine abdomen Doppler ultrasonography during followup at the outpatient clinic (at 3, 6, 12, and 24 months). Histopathologic data of IVC involvement
Pathologic characteristics of primary and metastatic tumors are reported in Tables 1 and 2, respectively. Mean diameter of primary tumors was slightly higher as compared with metastatic lesions (8.24 ⫾ 4.38 cm versus 7.16 ⫾ 4.18 cm), without statistical significance. Histologic invasion into the IVC was proved in 13 patients (68.4%). In the other six patients, only a simply adhesion was observed. It is interesting to observe that IVC infiltration was always present when the tumor had a diameter ⱖ6 cm, and IVC infiltration occurred in only 33% of tumors ⬍6 cm; this difference did not reach statistical significance. DISCUSSION Development of liver transplantation and new techniques of vascular control have drastically contributed to extending the indication for liver resection to advanced tumors, including those infiltrating the retrohepatic IVC.15-21 In the present series, we report our experience with 19 liver resections combined with different types of IVC resection and reconstruction. They represent 2.9% of liver resections for liver malignancies at our institute. To the best of our knowledge, this study is one of the largest experiences of liver resection with IVC resection and reconstruction reported in the literature (Table 3), including only series with three or more patients.1,4,8,9,11,22-31 The table does not report single or two-case reports.2,10,13,18,20,21,30,32-36 THVE must be used when necessary, within 60 minutes of ischemia, which
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Table 3. Reported Cases of Liver Resection with IVC and Reconstruction Because of a Hepatic Tumor Involving the IVCⴱ
First author, year
No. of cases Primary Secondary
Moriura, 199022
1
Habib, 199423
4
Huguet, 199511 Tanaka, 199624
3 5
Miyazaki, 19991
2
3
16
Chin, 199925 Bower, 19994
3
3 13
Madariaga, 200026
3
6
Lodge, 20008
3 Major hepatectomies 7 Major hepatectomies 2 Major hepatectomies 2 Minor hepatectomies 10 Major hepatectomies 1 Minor hepatectomy 2 Major hepatectomies 1 Minor hepatectomy 19 Major hepatectomies 3 Minor hepatectomies
1 5 3
Arii, 200329
8
3
Present study
6 Major hepatectomies 4 Minor hepatectomies 9 Major hepatectomies 8 Major hepatectomies 1 Minor hepatectomy 8 Major hepatectomies
2 2 1
Hemming, 20049
4 Major hepatectomies 1 Major hepatectomy 1 Minor hepatectomy 12 Major hepatectomies 4 Minor hepatectomies
8
Hardwigsen, 200127 Sener, 200231 Okada, 200328
Aoki, 200430
Surgical procedure
1 Major hepatectomy, 2 Minor hepatectomies 4 Major hepatectomies
3 14
8
8
11
15 Major hepatectomies 4 Minor hepatectomies
IVC repair
1 DS 2 AP 2 DS 1 AP 1 PTFEt 4 PTFEt 5 PTFEt 13 DS 2 AP 1 PTFEt 6 AP 13 PTFEt 4 Dacron 4 PTFEt 1 AP 1 DS 1 AP 6 PTFEt 3 PTFEt Not specified 2 DS 2 AP 10 PTFEt 1 Gore-Tex p 2 DS 1 AP 14 PTFEt 6 DS 2 PTFEp 12 DS 3 PBP 4 PTFEt
Recurrence
n
Outcomes Alive Died Mean time Mean time (mo) n (mo)
1
2
1
—
—
—
4 —
1
26 —
5
18 —
11
4
52.7
12
—
1 10
5 4
24 22
1 9
6 29
5
6
72
3
6
4
4
7
4
10
3 1 3
0 2 1
60 76
3 5 3
30.6 18 18.6
6
4
71.2
7
14.9
3
1
36.1
2
32.9
6
14
25.6
8
21.5
13
10
54.3
9
13.7
ⴱ
Series with less than three patients excluded. DS, direct suture; AP, autogenous patch; PTFEt, polytetrafluoroethylene patch.
should be the limit of liver tolerance.15 Normal liver tolerates normothermic ischemia up to 90 minutes, although this time becomes 60 minutes in the specific setting of pathologic liver.37 For this reason, veno⫺venous bypass and hypothermic perfusion should be used to make the liver more resistant for a more prolonged ischemic period.16,17,19 In our experience, THVE was applied in nine patients and mean duration was 33.9 minutes; veno⫺venous bypass was never required. Vascular access for bypass positioning (saphenous vein and left axillary vein) should be achieved in the event of hemodynamic instability during clamping. A
biopump with a heparinized wall circuit, commonly used in transplantation operations, should be prepared in the operating room when planning this type of operation. Similarly, we never used ex situ or in situ perfusion operations; in the patient in our series who died of liver failure after prolonged THVE (longer than 60 minutes) it might have been useful. We suggest that hepatobiliary surgeons should consider these techniques in carefully selected patients.38,39 In the Mayo Clinic series, a 13% operative mortality was considered acceptable, taking the complexity of the surgical procedure into consideration.4 Other authors have reported operative mortality
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⬎10%.11,37 In our series, the operative mortality was 5.9%; only one patient died, 3 days after the operation, as a result of liver failure. These results can be achieved only with careful patient selection. Different types of IVC repair have been applied, depending on the extent of IVC infiltration by the tumor. Partial invasion of the IVC wall is repaired by direct suture, if the wall is infiltrated for a short segment, ie, ⬍2 cm. A patch of autologous saphenous vein, fascial peritoneum,25 or heterologous materials10,35 can be used in the presence of extended infiltration of the wall, ie, ⬎2 cm, to prevent lumen stenosis. In the present series, a pericardium bovine patch was used in three patients. Finally, total replacement of the IVC with a vascular prosthesis is indicated if at least one half of the circumference of the IVC appears infiltrated or in the presence of a longitudinal infiltration, or, rarely, in the presence of an intracaval thrombus.4,11,20,33 Experimental studies have confirmed the long-lasting patency of the grafts.40,41 In agreement with other authors, we prefer PTFEt grafts for replacing the IVC. PTFEt grafts are available in various diameters and they seem to be resistant to theoretical compression of the abdominal viscera. Because these PTFEt grafts cause a pseudointimal layer, it is preferable to use grafts ⬎16 mm in diameter and as short as possible.41 In our series, PTFEt grafts were uses in four patients. Of these, one patient died in the immediate postoperative course, and in the other three patients the graft is still patent. Although the literature contains few data on this aspect, risk of infection of the grafts appears very low and we did not experience it in our series. A careful selection of the patients is mandatory for good results. Exclusion criteria for this type of operation are evidence of extrahepatic metastases.4 Good indications for operation are patients with well-localized tumors involving the IVC, without renal or hepatic insufficiency and with a preserved cardiac and pulmonary reserve. CT scan is the common radiologic assessment to define tumor extent and presence of extrahepatic disease. There is no agreement on preoperative use of cavography to assess neoplastic involvement of the IVC, despite use of CT or MRI. On the other hand, Kaneko and colleagues42 showed better results with endo-ultrasonography as compared with cavography in these patients. Sensitivity, specificity, and accuracy was significantly better than cavography.42 At present, the gold standard to evaluate IVC involvement is intraoperative ultrasonography, which is helpful in verifying tumor extent and degree of neoplastic infiltra-
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tion of the IVC wall and in studying the relationship between the tumor and hepatic veins.11,42 Data on the survival rate of the patients operated on for tumors with IVC involvement are rare and larger series are required to define the real survival benefit of such an aggressive procedure. Madariaga and colleagues26 reported on a series of liver resections for primary and metastatic tumors with a median survival of 66.5 months (range 6 to 156 months). In the Aoki and colleagues series30 of metastatic colorectal cancer, median survival time was 25.8 months, with only one 3-year survivor. In the present study, median survival time was 32 months with a range of 3 months to 125 months. This is quite a satisfactory result compared with the dismal natural history of these patients.43,44 According to observations of some Japanese authors, survival results could be interpreted in the context of tumor pathology.28,29 In particular, a recent study from Okada and colleagues28 suggested that it can be difficult to determine real tumor involvement of the IVC, and suggested that the surgeon should endeavor to peel the tumor from the IVC to avoid unnecessary resection of the IVC. Interestingly, there were eight patients with a tumor size ⬍6 cm in the 19 patients of our series. Six of these patients did not have tumor invasion of the IVC, just adhesion. All of these were metastatic lesions. Finally, we want to stress that seven patients (36.8%) underwent major caval resections; all but one had a neoplastic infiltration of the IVC wall demonstrated by histology and three of them are currently alive and well. In conclusion, IVC involvement should not be considered an absolute contraindication to operation in patients with liver tumors. Because of the lack of alternative procedures to operation, hepatic resection remains the only possibility to achieve satisfactory survival with an acceptable death rate in selected patients in tertiary hepatobiliary centers. Different types of IVC replacement can be applied on the basis of intraoperative findings and experience. Author Contributions
Study conception and design: Nardo, Montalti, Gardini Acquisition of data: Bertelli, Beltempo, Puviani, Pacilè Analysis and interpretation of data: Nardo, Ercolani, Vivarelli Drafting of manuscript: Nardo, Ercolani Critical revision: Cavallari
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