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Azoulay D, Salloum C, Allard MA, Serrablo A, Moussa M, Romano P, Pietraz D, Golse N, Lim C. Complex Hepatectomy Under Total Vascular Exclusion of the Liver Preserving the Caval Flow with Portal Hypothermic Perfusion and Temporary Portacaval Shunt: A Proof of Concept. Ann Surg Oncol 2024:10.1245/s10434-024-15227-7. [PMID: 38592622 DOI: 10.1245/s10434-024-15227-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/12/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Hypothermic liver perfusion decreases ischemia/reperfusion injury during hepatectomy under standard total vascular exclusion (TVE) of the liver. This surgery needs venovenous bypass and is hampered by high morbi-mortality. TVE preserving the inferior vena cava (IVC) flow is hemodynamically well tolerated but remains limited in duration when performed under liver normothermia. The objective of this study was to report the results of TVE preserving the caval flow, modified to allow hypothermic liver perfusion and obviate splanchnic congestion. PATIENTS AND METHODS The technique, indicated for tumors abutting large tributaries of the hepatic veins but sparing their roots in IVC and the latter, was applied when TVE was anticipated to last for ≥ 60 min. It combines continuous TVE preserving the IVC flow with hypothermic liver perfusion and temporary portacaval shunt (PCS). Results are given as median (range). RESULTS Vascular control was achieved in 13 patients with excellent hemodynamical tolerance. PCS was direct or via an interposed synthetic graft (five and eight cases, respectively). Liver temperature dropped to 16.5 (6-24) °C under perfusion of 2 (2-4) L of cold perfusate. TVE lasted 67 (54-125) min and 4.5 (0-8) blood units were transfused. Resection was major in nine cases and was complete in all cases. Five complications occurred in four patients, and the 90-day mortality rate was zero. CONCLUSIONS This technique maintains stable hemodynamics and combines the advantages of in situ or ex situ standard TVE with hypothermic liver perfusion, without their inherent prolongation of ischemia time and need for venovenous bypass.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France.
| | - Chady Salloum
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Marc-Antoine Allard
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Maya Moussa
- Centre Hépato-Biliaire, Department of Anesthesiology, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Pierluigi Romano
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Daniel Pietraz
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Nicolas Golse
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Chetana Lim
- Department of Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Villejuif, France
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Azoulay D, Desterke C, Bhangui P, Serrablo A, De Martin E, Cauchy F, Salloum C, Allard MA, Golse N, Vibert E, Sa Cunha A, Cherqui D, Adam R, Saliba F, Ichai P, Feray C, Scatton O, Lim C. Rescue Liver Transplantation for Posthepatectomy Liver Failure: A Systematic Review and Survey of an International Experience. Transplantation 2024; 108:947-957. [PMID: 37749790 DOI: 10.1097/tp.0000000000004813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Rescue liver transplantation (LT) is the only life-saving option for posthepatectomy liver failure (PHLF) whenever it is deemed as irreversible and likely to be fatal. The goals were to perform a qualitative systematic review of rescue LT for PHLF and a survey among various international LT experts. METHODS A literature search was performed from 2000 to 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Population, Intervention, Comparison, Outcome framework, and to this, the authors' experience was added. The international online open survey included 6 cases of PHLF extracted from the literature and submitted to 976 LT experts. The primary outcome was whether experts would consider rescue LT for each case. Interrater agreement among experts was calculated using the free-marginal multirater kappa methodology. RESULTS The review included 40 patients. Post-LT mortality occurred in 8 (20%) cases (7/28 with proven cancer and 1/12 with benign disease). In the long term, 6 of 21 (28.6%) survivors with cancer died of recurrence (median = 38 mo) and 15 (71.4%) were alive with no recurrence (median = 111 mo). All 11 survivors with benign disease were alive and well (median = 39 mo). In the international survey among experts in LT, the percentage agreement to consider rescue LT was 28%-98%, higher for benign than for malignant disease ( P = 0.011). Interrater agreement for the primary endpoint was low, expected 5-y survival >50% being the strongest independent predictor to consider LT. CONCLUSIONS Rescue LT for PHLF may achieve good results in selected patients. Considerable inconsistencies of decision-making exist among LT experts when considering LT for PHLF.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Christophe Desterke
- University of Medicine Paris Saclay, Le Kremlin-Bicêtre, France
- INSERM Unit UMR1310, Villejuif, France
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Eleonora De Martin
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - François Cauchy
- Department of Hepato-biliary and Pancreatic Surgery and Liver Transplantation, University of Geneva, Geneva, Switzerland
| | - Chady Salloum
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Marc Antoine Allard
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Nicolas Golse
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Eric Vibert
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Antonio Sa Cunha
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - René Adam
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Faouzi Saliba
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Philippe Ichai
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Cyrille Feray
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Olivier Scatton
- Département de Chirurgie et Transplantation Hépatique, Hôpital Universitaire Pitié-Salpêtrière, Sorbonne Université, Paris, France
- Centre de Recherche de Saint-Antoine (CRSA), INSERM, UMRS-938, Paris, France
| | - Chetana Lim
- Département de Chirurgie et Transplantation Hépatique, Hôpital Universitaire Pitié-Salpêtrière, Sorbonne Université, Paris, France
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Azoulay D, Desterke C, Bhangui P, Salloum C, Conticchio M, Vibert E, Cherqui D, Adam R, Ichai P, Saliba F, Elmaleh A, Naili S, Lim C, Feray C. Tumors located in the central column of the liver are associated with increased surgical difficulty and postoperative complications following open liver resection for colorectal metastases. HPB (Oxford) 2022; 24:1376-1386. [PMID: 35437222 DOI: 10.1016/j.hpb.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/13/2022] [Accepted: 03/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND To assess the impact of difficult location (based on preoperative computed tomography) of liver metastases from colorectal cancer (LMCRC) on surgical difficulty, and occurrence of severe postoperative complications (POCs). METHODS A retrospective single-centre study of 911 consecutive patients with LMCRC who underwent hepatectomy by the open approach between 1998 and 2011, before implementation of laparoscopic surgery to obviate approach selection bias. LMCRC with at least one of the following four features on preoperative imaging: tumor invading the hepatocaval confluence or retro-hepatic inferior vena cava, centrally located (Segments 4,5,8) and >10 cm in diameter, abutting the supra-hilar area, or involving the paracaval portion or caudate process of Segment 1; were considered as topographically difficult (top-diff). Independent predictors of surgical difficulty assessed by number of blood units transfused, duration of ischemia, and number of sessions of pedicle clamping during surgery and of severe POCs were identified by multivariate analysis before, and after propensity score matching. RESULTS Top-diff tumor location independently predicted surgical difficulty. Severe POCs were associated with the tumor location [top-diff vs. topographically non difficult (non top-diff)], preoperative portal vein embolization, and variables related to surgical difficulty. CONCLUSION LMCRC in difficult location independently predicts surgical difficulty and severe POCs.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France.
| | - Christophe Desterke
- Université Paris-Saclay, Villejuif, France; Inserm UMR-S-MD A9, Hôpital Paul Brousse, Villejuif, France
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Chady Salloum
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Maria Conticchio
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Eric Vibert
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
| | - René Adam
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
| | - Philippe Ichai
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Faouzi Saliba
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Annie Elmaleh
- Service de Radiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse, Villejuif, France
| | - Salima Naili
- Département D'Anesthésie-Réanimation, Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Chetana Lim
- Département de Chirurgie Hépato-Biliaire et Transplantation Hépatique, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Cyrille Feray
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
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Kidney Disease: Improving Global Outcomes Classification of Chronic Kidney Disease and Short-Term Outcomes of Patients Undergoing Liver Resection. J Am Coll Surg 2022; 234:827-839. [DOI: 10.1097/xcs.0000000000000112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Azoulay D, Eshkenazy R, Pery R, Cordoba M, Haviv Y, Inbar Y, Zisman E, Lahat E, Salloum C, Lim C. The Impact of Establishing a Dedicated Liver Surgery Program at a University-affiliated Hospital on Workforce, Workload, Surgical Outcomes, and Trainee Surgical Autonomy and Academic Output. ANNALS OF SURGERY OPEN 2021; 2:e066. [PMID: 37636559 PMCID: PMC10455269 DOI: 10.1097/as9.0000000000000066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023] Open
Abstract
Objective To detail the implementation of a dedicated liver surgery program at a university-affiliated hospital and to analyze its impact on the community, workforce, workload, complexity of cases, the short-term outcomes, and residents and young faculties progression toward technical autonomy and academic production. Background Due to the increased burden of liver tumors worldwide, there is an increased need for liver centers to better serve the community and facilitate the education of trainees in this field. Methods The implementation of the program is described. The 3 domains of workload, research, and teaching were compared between 2-year periods before and after the implementation of the new program. The severity of disease, complexity of procedures, and subsequent morbidity and mortality were compared. Results Compared with the 2-year period before the implementation of the new program, the number of liver resections increased by 36% within 2 years. The number of highly complex resections, the number of liver resections performed by residents and young faculties, and the number of publications increased 5.5-, 40-, and 6-fold, respectively. This was achieved by operating on more severe patients and performing more complex procedures, at the cost of a significant increase in morbidity but not mortality. Nevertheless, operations during the second period did not emerge as an independent predictor of severe morbidity. Conclusions A new liver surgery program can fill the gap between the demand for and supply of liver surgeries, benefiting the community and the development of the next generation of liver surgeons.
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Affiliation(s)
- Daniel Azoulay
- From the Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, AP-HP, Université Paris-Saclay, Villejuif, France
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Rony Eshkenazy
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
- Intensive Care Unit, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ron Pery
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Mordechai Cordoba
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yael Haviv
- Intensive Care Unit, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yael Inbar
- Department of Radiology, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Eliyahu Zisman
- Department of Anesthesiology, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Eylon Lahat
- Department of General Surgery B, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Chady Salloum
- From the Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, AP-HP, Université Paris-Saclay, Villejuif, France
| | - Chetana Lim
- Department of HPB and Liver Transplantation, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
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