In Situ Hypothermic Perfusion of the Liver for Complex Hepatic Resection: Surgical Refinements

Vena cava replacement and major hepatectomy for liver tumors: international multicenter retrospective cohort study

INTRODUCTION

Involvement of the inferior vena cava (IVC) and hepatic veins has been considered a relative contraindication to hepatic resection for primary and metastatic liver tumors. However, patients affected by tumors extending to the IVC have limited therapeutic options and suffer worsening of quality of life due to IVC compression.

METHODS

Cases of primary and metastatic liver tumors with vena cava infiltration from 10 international centers were collected (7 European, 1 US, 2 Brazilian, 1 Indian) were collected. Inclusion criteria for the study were major liver resection with concomitant vena cava replacement. Clinical data and short-term outcomes were analyzed.

RESULTS

Thirty-six cases were finally included in the study. Median tumor max size was 98 mm (range: 25-250). A biliary reconstruction was necessary in 28% of cases, while a vascular reconstruction other than vena cava in 34% of cases. Median operative time was 462 min (range: 230-750), with 750 median ml of estimated blood loss and a median of one pRBC transfused intraoperatively (range: 0-27). Median ICU stay was 4 days (range: 1-30) with overall in-hospital stay of 15 days (range: 3-46), postoperative CCI score of 20.9 (range: 0-100), 12% incidence of PHLF grade B-C. Five patients died in a 90-days interval from surgery, one due to heart failure, one due to septic shock, and three due to multiorgan failure. With a median follow-up of 17 months (interquartile range: 11-37), the estimated 5 years overall survival was 48% (95% CI: 27-66%), and 5-year cumulative incidence of tumor recurrence was 55% (95% CI: 33-73%).

CONCLUSIONS

Major liver resections with vena cava replacement can be performed with satisfactory results in expert HPB centers. This surgical strategy represents a feasible alternative for otherwise unresectable lesions and is associated with favorable prognosis compared to nonoperative management, especially in patients affected by intrahepatic cholangiocarcinoma.

Highly complex liver resections: Exploring the boundaries of feasibility and safety

INTRODUCTION

In select clinical scenarios, advanced techniques for volume manipulation and vascular reconstruction are needed for complete hepatic tumor removal. These highly complex liver resections (HCLRs) entail a heightened risk of severe complications. Here, we describe the results of HCLR performed in a 3-year time period.

MATERIALS AND METHODS

We conducted a retrospective analysis encompassing patients who underwent hepatic resections between June 15, 2020, and June 15, 2023. HCLR was defined according to previously established criteria, and included associating liver partition and portal vein ligation for staged hepatectomy. The outcomes of HCLR were compared to all non-HCLR performed within the same time frame.

RESULTS

Among 167 hepatic resections, 26 were considered HCLR, and all were major resections. Five utilized total vascular exclusion, with venovenous bypass in three, and hypothermic liver perfusion in three. Five resections included vascular reconstructions, and one included hypothermic circulatory arrest for extraction of a tumor extending to the right atrium. Of the non-HCLR, 38 (26.9%) were major, and 49 (34.7%) were performed laparoscopically. The rates of overall major postoperative complications were comparable between those who underwent HCLR versus non-HCLR. HCLR was associated with increased rates of biliary complications, readmissions, and reoperation. However, no postoperative 90-day mortality was documented within patients that underwent HCLR compared to two in the non-HCLR group.

CONCLUSIONS

In expert hands, HCLR can be performed with acceptable complication profile, akin to that of major non-HCLR. Those with questionable resectability should be referred to tertiary hepato-pancreato-biliary centers.

Extended Right Hepatectomy to Inferior Vena Cava Under Total Vascular Exclusion, Veno-Venous Bypass and In Situ Hypothermic Perfusion of the Future Liver Remnant

BACKGROUND

Venous obstruction at the hepatic veins-inferior vena cava confluence can be particularly challenging to manage if an associated liver resection is needed. Total vascular exclusion (TVE) with veno-venous bypass (VVB) and hypothermic in situ perfusion (HP) of the future liver remnant can be used in these conditions.1,2 METHODS: The patient was a 58-year-old with a voluminous adrenal cancer invading the kidney, the right liver and the retrohepatic inferior vena cava with intraluminal thrombus extending up to the hepatic veins confluence. A right hepatectomy, extended to segment 1, the right kidney, and the retrohepatic inferior vena cava was planned.

RESULTS

The parenchymal liver transection was performed under a TVE, VVB, and HP of the left liver to decrease blood losses and risk of postoperative liver failure. Vena cava reconstruction was achieved by a ringed Gore-Tex prosthesis with reimplantation of the left renal vein. Total duration of veno-venous bypass and liver vascular exclusion were 2 h 40 min and 2 h 10 min, respectively. The patient was discharged on postoperative day 17.

CONCLUSIONS

Total vascular exclusion with veno-venous bypass and in-situ liver hypothermic perfusion increases the safety of major liver resection requiring complex vascular reconstruction.1,2 TVE under VVB and HP of the future liver remnant is used at our institution when: (1) TVE will last more than 30 min; (2) vascular reconstruction is needed; (3) in the presence of venous obstruction; (4) in the presence of injured liver parenchyma; and (5) in the presence of cardiovascular comorbidities.

Left renal vein graft and in situ hepatic perfusion in hepatectomy for complete tumor invasion of hepatic veins: hemodynamic optimization and surgical technique

Purpose

Assessing hepatic vein reconstruction using a left renal vein graft and in situ hypothermic liver perfusion in an extended liver resection.

Methods

Patients included in this study were those with liver tumors undergoing curative surgery with resection and reconstruction of hepatic veins. Hepatic vein was reconstructed using a left renal vein graft. We describe the technical aspects of liver resection and vascular reconstruction, the key aspects of hemodynamic management, and the use of in situ hypothermic liver preservations during liver transection (prior to and during vascular clamping).

Results

The right hepatic vein was reconstructed with a median left renal venal graft length of 4.5 cm (IQR, 3.1–5.2). Creatinine levels remained within normal limits in the immediate postoperative phase and during follow-up. Median blood loss was 500 ml (IQR, 300–1500) and in situ perfusion with cold ischemia was 67 min (IQR, 60.5–77.5). The grafts remained patent during the follow-up with no signs of thrombosis. No major postoperative complications were observed.

Conclusion

Left renal vein graft for the reconstruction of a hepatic vein and in situ hypothermic liver perfusion are feasible during extended liver resection.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02451-6.

Single-Centre Experience of Supra-Renal Vena Cava Resection and Reconstruction

BACKGROUND

Tumours involving the supra-renal segment of IVC have dismal prognosis if left untreated. Currently, aggressive surgical management is the only potentially curative treatment but is associated with relatively high morbidity and mortality. This study aims to evaluate perioperative factors, associated with adverse postoperative outcomes, based on the perioperative characteristics and type of IVC reconstruction.

METHODS

We identified 44 consecutive patients, who underwent supra-renal IVC resection with a mean age of 57.3 years. Isolated resection of IVC was performed in four patients, concomitant liver resection was performed in 27 patients and other associated resection in 13 patients. Total vascular exclusion was applied in 21 patients, isolated IVC occlusion in 11 patients. Neither venovenous bypass (VVB) nor hypothermic perfusion was used in any of the cases.

RESULTS

The mean operative time was 205 min (150-324 min) and the mean estimated blood loss was 755 ml (230-4500 ml). Overall morbidity was 59% and major complications (Dindo-Clavien ≥ III) occurred in 11 patients (25%). The 90-day mortality was 11% (5pts). Intraoperative haemotransfusion was significantly associated with postoperative general complications (p < 0,001). With a mean follow-up of 26.2 months, the actuarial 1-, 3- and 5-year survival is 69%, 34%, and 16%, respectively.

CONCLUSIONS

IVC resection and reconstruction in the aspect of aggressive surgical management of malignant disease confers a survival advantage in patients, often considered unresectable. When performed in experienced centres it is associated with acceptable morbidity and mortality.

Transferability of Liver Transplantation Experience to Complex Liver Resection for Locally Advanced Hepatobiliary Malignancy - Lessons Learnt From 3 Decades of Single Center Experience

OBJECTIVE

To study the impact of LT experience on the outcome of CLR for locally advanced hepatobiliary malignancy SUMMARY OF BACKGROUND DATA:: Despite evolution in LT knowledge and surgical techniques in the past decades, there is yet data to evaluate the significance of LT experience in performing CLR.

METHODS

Postoperative outcome after CLR between 1995 and 2019 were reviewed and correlated with LT experience in a single center with both LT and CLR service. CLR was defined as hepatectomy with vasculobiliary reconstruction, or multivisceral resection, central bisectionectomy (S4/5/8), or associating liver partition and portal vein ligation for staged hepatectomy. Spearman rank correlation and receiver operating characteristic analysis were used to define the association between CLR-related outcomes and LT experience.

RESULTS

With cumulative single-center experience of 1452 LT, 222 CLR were performed during the study period [hepatectomy with biliary (27.0%), or vascular (21.2%) reconstruction, with multivisceral resections (9.9%), with associating liver partition and portal vein ligation for staged hepatectomy (18.5%)] mainly for hepatocellular carcinoma (53.2%), and hilar cholangiocarcinoma (14%). Median tumor size was 7.0 cm. Other features include macrovascular invasion (23.4%), and juxta-visceral invasion (14%). Major postoperative complication rate was 25.2% and mortality rate was 6.3%. CLR-complication rate was inversely associated with LT experience (R = -0.88, P < 0.005). Receiver operator characteristic analysis revealed the cutoff for LT experience to have the greatest influence on CLR was 95 with a sensitivity of 100% and Youden index of 1. Multivariable analysis showed that blood transfusion, prolonged operating time, LT experience </=95 were associated with major postoperative complications.

CONCLUSION

LT experience was complimentary to CLR for locally advanced hepatobiliary malignancy with improved postoperative outcome.

Case series of extended liver resection associated with inferior vena cava reconstruction using peritoneal patch

INTRODUCTION

Among various reported techniques for inferior vena cava (IVC) reconstruction, the superiority of one technique over another has not been clearly established. This study aimed at reporting the technical aspects of caval reconstruction using peritoneal patch during extended liver resections.

METHODS

All consecutive patients who underwent extended liver resection associated with anterolateral caval reconstruction using a peritoneal patch from 2016 to 2019 were included in this study. Technical insights, intra-operative details, short and long-term results were reported.

RESULTS

Overall six patients underwent caval reconstruction using peritoneal patch under total vascular exclusion. Half of them required veno-venous bypass. Caval involvement ranged from 30 to 50% of the circumference and from 5 to 7 cm of the length of the IVC. Caval reconstructions was performed using a peritoneal patch harvested from the falciform ligament in four cases and from the right pre-renal peritoneum and right part of the diaphragm in one Case each. Three cases underwent associated reimplantation the remnant hepatic vein. Median intra-operative blood loss and TVE duration were 500 ml and 41 min, respectively. One case experienced a severe complication (liver failure leading to death). R₀ resection was achieved in all patients. All patients had patent IVC and remnant hepatic vein at last follow-up and none was on long-term therapeutic anticoagulation.

CONCLUSION

Caval reconstruction using a peritoneal patch in patients undergoing extended liver resection is feasible and cost-effective and associated with excellent long-term results.

Complex liver resection under hepatic vascular exclusion and hypothermic perfusion with versus without veno-venous bypass: a comparative study

BACKGROUND

While hypothermic liver perfusion has been shown to improve parenchymal tolerance to complex resections in patients requiring prolonged hepatic vascular exclusion (HVE), the benefit of associated veno-venous bypass (VVB) in this setting remains poorly evaluated.

METHODS

All patients undergoing liver resection requiring HVE and hypothermic liver perfusion for at least 55 min between 2006 and 2017 were retrospectively reviewed. Perioperative outcomes were compared between patients with (VVB+) or without VVB (VVB-).

RESULTS

Twenty-seven patients were analyzed, including 13 VVB+ and 14 VVB-. Median HVE duration was similar in VVB+ and VVB- patients (96 vs. 75 min, respectively). VVB+patients had longer operative time (460 vs. 375 min, p = 0.023) but less blood loss (p = 0.010). Five (19%) patients died postoperatively from liver failure or sepsis, without difference between groups. Postoperative major morbidity rate was similar between VVB+ and VVB- patients (30% vs. 50%, respectively) such as rates of liver failure, haemorrhage, renal insufficiency and sepsis, but VVB- patients experienced more respiratory complications (64% vs. 15%, p = 0.012).

CONCLUSION

During liver resection under HVE and hypothermic liver perfusion, use of VVB allows for reducing blood loss and postoperative respiratory complications. VVB should be recommended in case of liver resection with prolonged HVE.

Enhanced Recovery in Liver Transplantation: A Feasibility Study

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programmes after surgery are effective in reducing length of stay, functional recovery and complication rates in liver surgery (LS) with the indirect advantage of reducing hospitalisation costs. Preoperative comorbidities, challenging surgical procedures and complex post-operative management are the points that liver transplantation (LT) shares with LS. Nevertheless, there is little evidence regarding the feasibility and safety of ERAS programmes in LT.

METHODS

We designed a pilot, small-scale, feasibility study to assess the impact on hospital stay, protocol compliance and safety of an ERAS programme tailored for LT. The ERAS arm was compared with a 1:2 match paired control arm with similar characteristics. All patients with MELD <25 were included. A dedicated LT-tailored protocol was derived from publications on ERAS liver surgery.

RESULTS

Ten patients were included in the Fast-Trans arm. It was observed a 47% reduction of the total LOS, as compared to the control arm: 9.5 (9.0-10.5) days versus 18.0 (14.3-24.3) days, respectively, p <0.001. The protocol achieved 72.9% compliance. No differences were observed in terms of post-operative complications or readmission rates after discharge between the two arms. Overall, it was observed a reduction of length of stay in ICU and surgical ward in the Fast-Trans arm compared with the control arm.

CONCLUSION

Considered the main points in common between LS and LT, this small-scale study suggests that the application of an ERAS programme tailored to the LT setting is feasible. Further testing will be appropriate to generalise these findings.

Long-Term Outcomes of Ante-Situm Resection and Auto-Transplantation in Conventionally Unresectable Hepatocellular Carcinoma: A Single-Center Experience

Background

Ante-situm resection and auto-transplantation (ante-situm for short) provides a more aggressive approach to conventionally unresectable hepatocellular carcinoma (HCC). We described the long-term outcomes of patients with HCCs who underwent this technique.

Material/Methods

Between October 2005 and December 2016, we performed 23 ante-situm liver resections. We evaluated postoperative complications, 90-day mortality, recurrence, and long-term survival rates, and reviewed the literature on this topic.

Results

Five types of complications associated with six patients were observed.: 1) primary nonfunctioning liver, thus receiving a liver transplantation; 2) initial poor liver function with recovery two weeks after treatment; 3) diagnoses of portal vein tumor thrombosis, biliary fistula, and small-for-size syndrome, respectively. The median follow-up was 3.6 years; 12 out of 23 patients were alive at the end of the study. One patient who had hepatic recurrence was lost to follow-up after three months. One patient died of multiple organ dysfunction syndrome after the operation, nine patients died due to hepatic recurrence and/or extrahepatic metastasis of HCC. The one-year, three-year, five-year, and 10-year survival rates were 65.2%, 56.5%, 50.9%, and 20.3%, respectively. The one-year, three-year, five-year, and 10-year recurrence rates were 60.9%, 50.7%, 50.7%, and 50.7%, respectively. The chi-square test revealed the patients with recurrence after ante-situm technique were more likely to have poor prognosis (mortality of patients with recurrence versus no-recurrence: 88.9% versus 14.3%, p<0.05) and a strong association was evidenced by Cramer’s V statistic (Cramer’s V=0.734).

Conclusions

Ante-situm procedure showed benefits in select patients with HCCs who had contraindications for conventional resection operations. In our case series, the ante-situm technique resulted in lower mortality compared to other ex-vivo hepatic resection techniques reported in the literature and similar long-term efficacy compared to cases of HCCs suitable for conventional resections. HCCs recurrence was a major risk factor associated with the survival rate of ante-situm technique.