Asian Journal of Surgery 43 (2020) 698e699

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Asian Journal of Surgery
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Letter to Editor

The high complexity major liver resection by Thunderbeat with thePringle maneuver and infra-hepatic inferior vena cava clamping
Dear Editor,
In addition to conventional major or minor classiﬁcation in liverresection (LR), recently, a complexity classiﬁcation with 3 categories (low, medium, or high) according to its technical difﬁculty
was proposed and validated.1e3 The high complexity major LR,both major LR and those classiﬁed under high complexity classiﬁcation, is one of the most challenging procedures in hepatobiliary surgery. We described the outcomes of the high complexity major LR
by Thunderbeat® (TB) (Olympus Medical Systems Corp., Tokyo,Japan) with the Pringle maneuver and infra-hepatic inferior vena
cava (IVC) clamping.
Of 79 patients undergoing LR between July 2013 and July 2019 at
our institution, we reviewed six patients who underwent this procedure (Table 1). Following the Pringle maneuver and infra-haptic
IVC clamping, the transection of the liver parenchyma was started
with TB under symmetric stay sutures on the hepatic edges. During
parenchymal transection, only the pedicles that were equal or

larger than 3rd branches of Glissonean pedicles or main branches ofmajor hepatic veins were ligated and divided, the other smaller
ones were generally sealed with TB. To evaluate the safety andrapidity of this procedure, we compared the parenchymal transection time (PTT), estimated blood loss (EBL), and postoperative major complications (PMC) deﬁned as Clavien-Dindo (CD)classiﬁcation4  3a with nine patients who underwent medium
or high complexity open major LR by the basic procedure, i.e. LR
by the clamp-crushing and/or the CUSA with supplemental use ofHarmonic Scalpel within same periods. PTT indicated the duration
recorded from the beginning of the parenchymal resection to theremoval of the en-bloc specimen of liver. The postoperative liver
dysfunction was assessed based on Balzan 50e50 criteria.5
Six patients underwent extended right hepatectomy with hepaticojejunostomy (n ¼ 3), anatomical middle hepatectomy (n ¼ 1),
and right trisectionectomy (n ¼ 1) or extended left hepatectomy(n ¼ 1) with IVC resection and reconstruction. The median PTTand EBL was 18 min and 1420 ml. Two patients experienced PMC.

Table 1
Characteristics and outcomes of patients.
Patient #1

2

3

4

56Age, (years)
Gender
BMI (kg/mm2)
Diagnosis

76
Woman
22.7
HCC74
Woman
24.1
Perihilar
cholangiocarcinoma
Yes
Extended righthepatectomy andhepaticojejunostomy
13371
1460
Yes
436
Negative

62
Man
16.7
CRLM

No
Anatomical
middlehepatectomy
45260
1380
No342
Negative

73
Man
21.7
Perihilar
cholangiocarcinoma
YesExtended righthepatectomy andhepaticojejunostomy
17458
2395
Yes
714
Negative

65
Man
15.6
HCC

RPVE
Operation

67
Man
26.3
CRLM with central biliary
invasion
Yes
Extended righthepatectomy andhepaticojejunostomy
16596
2730
Yes
940
Positive

No
No
Right trisectionectomy Extended left
and IVC reconstruction hepatectomy and IVC
reconstruction
2719217
209
1050
540
Yes
No
800
274
Negative
Negative

5128
Heparin-induced bleeding(CD3b)
No

360
No

17No

18NoNo268
Hepaticojejunostomy
failure (CD3a)
NoNo

NoNo

Alive/41

Alive with recurrence/34

Alive/28

Alive/27

Alive/4

Alive/4

PTT (min)OD (min)
EBL (mL)BTLWR (g)Surgicalmargin
ICU stay (days) 6
LOS (days)
19
PMC (CD ≥ 3a) No
Postoperativeliverdysfunction
Survival/(months)

BMI: body mass index, HCC: hepatocellular carcinoma, CRLM: colorectal cancer liver metastasis, RPVE: right portal vein embolization, IVC: inferior vena cava, PTT: parenchymal transection time, OD: operation duration, EBL: estimated blood loss, BT: blood transfusion, LWR: liver weight removed, ICU: intensive care unit, LOS: length of hospitalstay, PMC: postoperative major complications, CD Clavien-Dindo.
https://doi.org/10.1016/j.asjsur.2020.01.001
1015-9584/© 2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Letter to Editor / Asian Journal of Surgery 43 (2020) 698e699

One patient developed hepaticojejunostomy failure requiring reperitoneal drainage by paracentesis (CD3a) and another developed
postoperative bleeding requiring exploratory laparotomy postoperative day (POD) 3 (CD3b). This patient received continuous administration of 10,000 units of heparin intravenously by 24 h from POD
1 and presented with clear, bloody ﬂuid discharge from a drainage
tube at POD 3. All patients are currently alive with (n ¼ 1) orwithout recurrence (n ¼ 5) with a median follow-up of 27.5
months. PTT (mean ± SD) in the TB group was signiﬁcantly shorter:
22.8 ± 10.8 compared to 79.1 ± 49.8 min in the basic group(p ¼ 0.010). There was no signiﬁcant difference in terms of EBL(1592 ± 753 vs. 1863 ± 1378 mL, p ¼ 1.000) and PMC (33 vs. 22%,p ¼ 0.634), respectively.
In summary, TB with the Pringle maneuver and infra-hepatic
IVC clamping is feasible and seems to offer the combination of
rapidity, simplicity, and safety during high complexity major LR.
However, the clinical beneﬁts and the inclusion criteria for major
and/or high complexity LR need to be clariﬁed from more big,robust and valid evidence.

https://doi.org/10.1016/j.asjsur.2020.01.001.

References
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2. Muangkaew P, Cho JY, Han HS, et al. Deﬁning surgical difﬁculty according to theperceived complexity of liver resection: validation of a complexity classiﬁcationin patients with hepatocellular carcinoma. Ann Surg Oncol. 2016;23:2602e2609.
3. Jang JS, Cho JY, Ahn S, et al. Comparative performance of the complexity classiﬁcation and the conventional major/minor classiﬁcation for predicting the difﬁculty of liver resection for hepatocellular carcinoma. Ann Surg. 2018;267:18e23.
4. Dindo D, Demartines N, Clavien PA. Classiﬁcation of surgical complications: anew proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205e213.
5. Balzan S, Belghiti J, Farges O, et al. The "50-50 criteria" on postoperative day 5:
an accurate predictor of liver failure and death after hepatectomy. Ann Surg.
2005;242:824e828. discussion 828-9.

Teruo Komokata*, Bibek Aryal, Nobuhiro Tada, Kensuke Nuruki
Department of Surgery, National Hospital Organization Kagoshima
Medical Center, Kagoshima, Japan

Acknowledgements
We thank Miss Tomoko Matsueda, Department of Surgery, National Hospital Organization Kagoshima Medical Center, for herkind assistance.

699*Corresponding author. Department of Surgery, National Hospital
Organization Kagoshima Medical Center, 8-1 Shiroyama-cho,Kagoshima City, 892-0853, Japan.
E-mail address: komokata.teruo.je@mail.hosp.go.jp (T. Komokata).

Appendix A. Supplementary data
Supplementary data to this article can be found online at27 December 2019
Available online 15 January 2020