Laparoscopic Right Hepatectomy after Right Hemiliver Radiation Lobectomy with Y90 SIRTspheres

Fernando Rotellar1, Fernando Pardo1, Alberto Benito2, Gabriel Zozaya1, Pablo Marti-Cruchaga1, Macarena Rodriguez-Fraile3, Jose Ignacio Bilbao4, Mercedes Inarrairaegui5, Bruno Sangro5. 1HPB and Liver Transplant. Department of Abdominal and General Surgery. Clinica Universidad de Navarra. Pamplona. Spain., 2Abdominal Radiology. Department of Radiology.Clinica Universidad de Navarra. Pamplona. Spain., 3Nuclear Medicine. .Clinica Universidad de Navarra. Pamplona. Spain., 4Interventional Radiology .Clinica Universidad de Navarra. Pamplona. Spain., 5Hepatology. .Clinica Universidad de Navarra. Pamplona. Spain.

Liver surgery after selective internal Radioembolization (SIRT) has been scarcely reported.It has been claimed that (open) liver surgery after right lobe SIRT can be technically demanding due to possible firm adhesions between the right liver and the diaphragm /caval vein. The combination of laparoscopic approach post-SIRT is a complex scenario that to our knowledge has not been reported.

Patients and Methods: From July´2007 –July´2015, 40 patients with liver tumors treated with SIRT underwent R0 resections in our center: 30 resections and 10 liver transplants.

From March´2011 -January´2015, 5 (out of those 30) patients underwent post-Sirt full-laparoscopic resection:

One laparoscopic resection of an HCC in segment-VI. It had received previous segment-VI SIRT.

Three patients underwent laparoscopic right hepatectomy after previous right hemiliver radiation lobectomy: two cirrhotic patients with HCC and one with CCR liver metastasis.

Finally, a patient with a BuddChiari Sd, and a diffuse HCC in segment-III underwent left lobe radioembolization. After tumoral recurrence, a laparoscopic left lateral segmentectomy was performed.

In all cases, the procedure could be completed full-laparoscopic and none required transfusion. Hospital stay was 3,3,3,2 and 5 days.

Herein we present the case of a post-SIRT full-laparoscopic right hepatectomy:

CASE DESCRIPTION: This is the case of a 71 year-old patient with VHC cirrhosis previously treated with Telaprevir-PEG-Riba. In December 2013, a MRI detected a 35 mm lesion in segments V-VIII with AFP levels of 1668. In February 2014 underwent microwave ablation. In July 2014 local progression was detected with a diffuse tumor of 7×6,5 cm. Left liver volume was 435,9 ml (30% of the total liver volume). A right liver radiation lobectomy was performed with a single dose Y90 microspheres treatment administered through the right hepatic artery. Six months after, the tumor size was 4,5×3,5 cm with atrophy of the right liver and left side hypertrophy to 1128,4 ml (70% of the liver volume). Indocyanine green (ICG) clearance test values were: PDR:11,2%; R15:18,6%, thus allowing for resection of the 30% of the parenchyma.

The technique is described in detail in the video, which also shows the comparative hypoperfusion of the treated lobe revealed with ICG fluorescence.

Results: Operative time was 328 min. Hospital stay was 3 days. No early or late morbidity occurred. 8 months after the resection and 33 months after the initial diagnosis the patient is alive and free of disease.

Conclusion: Laparoscopic liver resection after SIRT is feasible and safe, even in major hepatectomies.

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