Surgical management of liver diseases invading the hepatocaval confluence based on IH classification: The surgical guideline in our center

Table 1 Patients undergoing combined liver and inferior vena cava resection

Indications for surgery	n	Sex (M:F), n	Classifications
			I1H1	I2H1	I1H2	I2H2	I3H1
Hepatocellular carcinoma	11	6:05	2	5	1	3	0
Cholangiocarcinoma	26	18:08	3	10	4	6	3
Colorectal metastases	8	5:03	1	5	0	1	1
Alveolar echinococcosis	9	5:04	3	3	0	2	1

Table 2 Intra- and postoperative results

Variables	I1H1 (n = 9)	I2H1 (n = 23)	I1H2 (n = 5)	I2H2 (n = 12)	I3H1 (n = 5)
					IVC resection and replacement (n = 2)	Only IVC resection (n = 3)
RL:REL:RT:LEL:LT	3:2:2:1:1	4:6:8:2:3	0:1:2:2:0	2:4:3:2:1	1:0:1:0:0	1:2:0:0:0
Tumor size (cm)	7.2 (2.9-14.3)	8.7 (7.1-15.4)	9.2 (3.9-9.9)	9.6 (7.2-16.1)	9.4 (6.6-12.2)	8.3 (7.1-10.2)
Operative blood loss (mL)	460 (310-950)	740 (450-1250)	570 (450-1050)	1020 (550-1700)a	680 (550-810)	450 (350-560)
Need for blood transfusion	1	8	0	7	1	0
Transfusion volume (mL)	400	550 (200-950)	0	600 (300-850)c	400	0
Operation duration (min)	290 (210-420)	592 (480-800)	520 (250-860)	750 (310-1150)a	580 (490-670)	320 (240-440)
No. of patients using TVE	2	23	3	12	2	0
No. of patients using PM	5	17	2	8	2	2
Duration of TVE (min)	50 (40,60)	62 (46-90)	48 (35-68)	73 (37-89)a	49 (39-57)	0
Duration of PM (min)	25 (10-35)	36 (15-45)	22.5(20-25)	38 (10-50)	30 (15-15)	30 (15-15)
Reconstruction detail	IVCR: direct suture in 4, with a patch in 5; HVR: no	IVCR: replacement; HVR: no	IVCR: with a patch in 5; HVR: reimplant to ePTFE in 1, to residual IVC in 4	IVCR: replacement; HVR: with a patch in 3, reimplant to ePTFE in 5, to residual IVC in 4	IVCR: replacement; HVR: no	IVCR: no; HVR: no
Surgical technique
Anti-situm	0	0	0	2	1	0
Ex vivo	0	0	0	6	0	0
In situ perfusion	0	2	1	5	0	0
Postoperative liver function
Serum maximum AST (IU/L)	460 (220-870)	557 (240-1240)	490 (230-590)	630 (330-1350)	520 (370,670)	665 (265-768)
Serum maximum ALT (IU/L)	565 (345-1350)	695 (230-1510)	520 (280-1020)	710 (340-1405)	610 (410-810)	685 (210-830)
Serum maximum PT (s)	14.1 (12.2-16.3)	15.4 (13.3-16.9)	14.8 (12.8-15.9)	15.4 (13.4-17.5)	16.4 (15.5-17.3)	15.5 (13.7-16.7)
Serum maximum TB (mmol/L)	33.4 (28.5-44.7)	36.8 (29.4-56.9)	33.7 (31.2-47.7)	45.0 (34.1-55.6)	35.0 (27.0-43.0)	33.1 (28.0-56.1)
Hospital stay (d)	11 (7-17)	15 (9-24)	12 (8-22)	19 (13-28)	14 (11-17)	16 (13-19)

Data are shown as median (range) or n.

^aP < 0.05 vs each other type;

^cP < 0.05 vs each other type except for I2H1. RL: Right lobectomy; REL: Right extended lobectomy; RT: Right tri-segmentectomy; LEL: Left extended lobectomy; LT: Left tri-segmentectomy; TVE: Total vessel exclusion; PM: Pringle maneuver; IVCR: Inferior vena cava reconstruction; HVR: Hepatic vein reconstruction; ALT: Alanine transaminase; AST: Aspartate transaminase; PT: Prothrombin time; TB: Total bilirubin.

Table 3 Postoperative complications

Variable	I1H1 (n = 9)	I2H1 (n = 23)	I1H2 (n = 5)	I2H2 (n = 12)	I3H1 (n = 5)
					IVC resection and replacement (n = 2)	Only IVC resection (n = 3)
Total number	1	8	2	8a	2	1
Biliary leak	1	1		1
Liver failure		2		2
Ascites	1	4	1	2	1	1
Jaundice				1
Hemorrhage requiring reoperation			1
Thrombosis of reconstructed vessels
Hepatic vein				1
Inferior vena cava		1
Intraabdominal abscess				1
Reconstructed vessel infection		2		2	1
Wound infection
Respiratory complication		1		1
Clavien-Dindo classification
Grade I-II	1	7	2	6	1	1
Grade III-V	1	4	0	5	1	0
90-d mortality	0	4	0	5a	0	0

Data are shown as n.

^aP < 0.05 vs I1H1; Liver failure: peak bilirubin concentration > 7 mg/dL, peak international normalized ratio > 2.0, refractory ascites, encephalopathy. Ascites: > 500 mL/d lasting longer than 3 d. IVC: Inferior vena cava.

Table 4 Univariate analysis of factors predictive of death

	All patients (n = 54)	Operative death		P value
		Yes (n = 9)	No (n = 45)
Age (yr)	49.7 (39-72)	53(45-72)	49 (39-67)	0.249
Sex ratio (M:F)	34:20	6:3	28:17	0.801
Preoperative chemotherapy	4	1	3	1.000
Preoperative PVE	9	2	7	1.000
Tumor type
Colorectal metastases	8	2	6	0.864
Hepatocellular carcinoma	11	2	9	1.000
Cholangiocarcinoma	26	4	22	1.000
Alveolar echinococcosis	9	1	8	1.000
Preoperative TB > 34 μmol/L	6	1	5	1.000
ICG-R15 over 10%	9	3	6	0.327
Child-Pugh B	6	4	2	0.004
No. of segments resected	4.7 (3-6)	5.1 (4-6)	4.6 (4-6)	0.189
Classifications				0.157
I1H1	9	0	9	0.328
I2H1	23	4	19	1.000
I1H2	5	0	5	0.576
I2H2	12	5	7	0.028
I3H1	5	0	5	0.576
IVC replacement
Yes (I2 + 2 cases in I3)	37	9	28	0.044
No (I1 + 3 cases in I3)	17	0	17
Hepatic vein reconstruction
Yes (H2)	17	4	13	0.600
No (H1)	37	5	32
Duration of ischemia (min)	68.7 (0-112)	87.7 (62-112)	64.9 (0-106)	< 0.001
Operative blood loss (mL)	721.5 (310-1250)	769.0 (550-1250)	712.3 (310-780)	0.389
Blood transfused amount (mL)	174.1 (0-950)	219.4 (0-950)	165.8 (0-850)	0.501
Duration of operation (min)	554.8 (210-1150)	709.6 (310-1150)	523.7 (210-860)	< 0.001
R0 resection	49	7	42	0.401
Tumor size	8.7 (2.9-16.1)	9.5 (8.8-16.1)	8.6 (2.9-15.4)	0.062

Data are shown as median (range) or n. PVE: Portal vein embolization; TB: Total bilirubin; ICG-R15: Indocyanine green retention rate at 15 min; IVC: Inferior vena cava.

Table 5 Multivariate binary logistic regression analysis of factors predictive of death

	OR (95%CI)	P value
IVC replacement	37.56 (1.46-945.32)	0.048
Duration of ischemia	1.65 (1.02-2.58)	0.005
Child B or C	1.82 (1.14-2.89)	0.025

IVC: Inferior vena cava.

Table 6 Literature review of the reported series of hepatectomies combined with inferior vena cava resection

Ref.	Hospital mortality	Hospital morbidity	No. alive/total (follow-up time)
DuBay et al[13]	11.1% (1 of gastrointestinal bleeding and multiple organ failure)	22.2%	6/9 (2-33 mo)
Malde et al[15]	11.4% (4 of multiple organ failure)	40.0%	16/35 (1-140 mo)
Azoulay et al[31]	4.5% (1 of sepsis and multiple organ failure)	64.0%	11/22 (7-84 mo)
Madariaga et al[21]	11.0% (1 of liver failure)	22.2%	6/9 (3-156 mo)
Giordano et al[25]	4.0% (1 of liver failure)	39.1%	16/23 (1-33 mo)
Hemming et al[24]	8.3% (liver failure and multiple organ failure)	43.0%	46/60 (median 31 mo)
Yamamoto[29]	28.6% (1 of sepsis, 1 of liver failure)	28.6%	2/7 (2-72 mo)
Lodge et al[10]	25% (1 of sepsis and multiple organ failure, 1 of respiratory and renal failure)	87.5%	7/8 (0.5-30 mo)

Table 7 Surgical technique of reported series of hepatectomies combined with inferior vena cava reconstruction

Ref.	Year	No. of cases	Indication	IVC repair type			Hepatic vein reconstruction	VVB	Perfusion	Technique	IVC reconstruction criteria
				Tube	Patch	Suture
DuBay et al[13]	2009	9	IVC leiomyosarcoma = 4; ICC = 2; PCC = 1; Metastases = 1; Malignant schwannoma = 1	7	0	0	Into the native IVC = 1; Into the graft = 5; Primary repair = 1	Not described	9	In situ perfusion	Not described
Malde et al[15]	2011	35	metastasis = 21; HCC = 6; ICC = 3; Other conditions = 5	11	2	22	Not described	Not described	12	In situ perfusion = 13; Anti situm = 3; Ex vivo = 6	< 2 cm: direct suture; > 2 cm: with patches; > 50% of the circumference and longitudinally infiltration: replacement
Azoulay et al[31]	2006	22	Metastasis = 9; ICC =8; HCC = 2; Other cancers = 3	10	4	8	Into the native IVC = 4; Into the graft =2	12	9	In situ perfusion = 9; Anti situm and ex vivo = 0; TVE only = 12; Others = 1	< 30% circumference: longitudinally suture; 30%-50% circumference: transversely suture; > 50% circumference: replacement
Madariaga et al[21]	2000	9	Metastasis = 1 IVC leiomyosarcoma = 3; ICC = 3; other cancers = 2	8	0	1	Into the graft = 1; Primary repair = 1	1	0	In situ perfusion, Anti situm and ex vivo = 0; TVE only = 3	Not described
Giordano et al[25]	2011	23	Metastases = 13; ICC = 3; HCC = 4; Others = 3	7	0	16	Into the graft = 1	4	4	In situ perfusion = 4; Anti situm = 0; Ex vivo = 0	< 30% of the circumference: suture; > 50% of the circumference: replacement
Hemming et al[24]	2012	60	ICC = 26; HCC = 16; Metastases = 13; Others = 5	38	14	8	Into the graft = 4	6 (ex vivo)	8	In situ perfusion = 8; Ex vivo = 6; Anti situm = 0	< 3 cm longitudinally: end-to-end anastomosis; > 5 cm sections of the anterolateral wall: with patches; 3-8 cm longitudinally : replacement
Yamamoto[29]	2012	7	ICC = 2; HCC = 5	4	1	2	Into the graft = 4	0	7	Anti-situm = 7	> 50% of the circumference: replacement
Lodge et al[10]	1999	8	Metastasis = 8	3	4	1	Into the native IVC = 1; Into the graft = 3	6 (4 ex vivo and 2 TVE)	Not described	Ex vivo = 4; TVE only = 4; Anti situm = 0	< 60° circumferentially and < 2 cm longitudinally: clamp tangentially

PCC: Perihilar cholangiocarcinoma; IVC: Inferior vena cava; HCC: Hepatocellular carcinoma; ICC: Cholangiocarcinoma.