576 Seyama et al SurgeryMay 2002

meticulous hemostasis was applied to both theresected and remnant sides of the liver, as in living-donor hepatectomy, the amount of blood loss wasacceptable, despite the presence of secondaryBudd-Chiari syndrome and even though the liverwas the main pathway of inferior caval blood flow.

We previously reported that a liver operationwithout TVE was safe and effective for removingeven a tumor located in the caudate lobe and sus-pected to involve the IVC.6 Therefore, practicalindications for TVE may be restricted to patientswith a tumor thrombus budding into the IVC orwidespread tumor invasion to the IVC wall. In suchpatients, intermittent TVE with caval flow clampingis desirable surgical option. To reduce the durationof TVE, we can limit the use of TVE near the IVCwhere thick communicating veins were encoun-tered and the amount of bleeding tended toincrease.

To our knowledge, this is the first report of suc-cessful intermittent TVE, which is a safe and bene-ficial method in patients with a hepatic tumor

involving the IVC or with secondary Budd-Chiarisyndrome.

REFERENCES1. Belghiti J, Noun R, Zante E, Thierry B, Sauvanet A. Portal

triad clamping or hepatic vascular exclusion for major liverresection. A controlled study. Ann Surg 1996;224:155-61.

2. Elias D, Lasser P, Debaene B, Doidy L, Billard V, Spencer A,et al. Intermittent vascular exclusion of the liver (withoutvena cava clamping) during major hepatectomy. Br J Surg1995;82:1535-9.

3. Nagasue N, Yukaya H, Ogura Y, Hirose S, Okita M.Segmental and subsegmental resection of the cirrhotic liverunder hepatic inflow and outflow occlusion. Br J Surg1985;72:565-8.

4. Makuuchi M, Mori T, Gunven P, Yamazaki S, Hasegawa H.Safety of hemihepatic vascular occlusion during resectionof the liver. Surg Gynecol Obstet 1987;164:155-8.

5. Belghiti J, Noun R, Malafosse R, Jagot P, Sauvanet A,Pierangeli F, et al. Continuous versus intermittent portaltriad clamping for liver resection: a controlled study. AnnSurg 1999;229:369-75.

6. Torzilli G, Makuuchi M, Midorikawa Y, Sano K, Inoue K,Takayama T, et al. Liver resection without total vascular exclu-sion: hazardous or beneficial? Ann Surg 2001;233:167-75.

Surgery is abstracted and/or indexed in Index Medicus, Science Citation Index, Current Contents/Clinical Medicine, Current Contents/Life Sciences, and MEDLINE.

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