Hepatic vein management in a parenchyma-sparing policy for resecting colorectal liver metastases at the caval confluence

Background: Patients with tumors involving hepatic vein at the caval-confluence usually receive major hepatectomies or hepatic vein grafting; however, nonnegligible postoperative mortality and morbidity are associated. Authors introduced the tumor-vessel detachment for colorectal liver metastases. Then we reviewed our results applying this approach in patients with colorectal liver metastases in contact with hepatic veins at the caval-confluence. Methods: A cohort of consecutive patients with colorectal liver metastases in contact with hepatic veins at the caval-confluence undergoing liver surgery was reviewed. Relationships were classified as: Type 1: contact/involvement less than a third of hepatic vein circumference; Type 2: contact/involvement in a third to two-thirds; Type 3: contact/involvement in more than two-thirds. Hepatic vein- colorectal liver metastases detachment, or in case of hepatic vein-resection, the sparing of the drained parenchyma, were attempted systematically. Results: Overall 190 colorectal liver metastases-hepatic vein contacts in 135 patients were analyzed. Colorectal liver metastases-hepatic vein detachment was performed in 95 (50%) contacts, partial resection and direct suture in 61 (32%), partial resection and patching in 4 (2%), and hepatic vein complete resection in 30 (16%). Hepatic vein-sparing resection was possible in 102 patients (76%), and major hepatectomy was needed in 1 (0.7%). Operative mortality, overall and major morbidity rate were 0.7%, 32%, and 4%, respectively. Local recurrence rate was 6% (median follow-up: 27 months). Preoperative and intraoperative imaging predicted the need for hepatic vein resection in 99% of patients (κ = 0.971). Conclusions: Hepatic vein-sparing or a parenchyma-sparing policy is feasible in most patients with colorectal liver metastases-hepatic vein contacts at the caval-confluence. This approach seems safe, predictable, and oncologically adequate, and, upon further confirmation, could become an alternative to major hepatectomies or hepatic vein replacement.