Liver autotransplantation and retrohepatic vena cava reconstruction for alveolar echinococcosis

Complex inferior vena cava reconstruction during ex vivo liver resection and autotransplantation: A case report

BACKGROUND

Ex vivo liver resection and autotransplantation (ELRA) is an essential approach for treating patients with end-stage hepatic alveolar echinococcosis (AE), and its surgical indications involve severe invasion of important hepatic vessels, which makes in vivo resection impossible. Revascularization is a major step in the process of ELRA, which is extremely challenging when the invaded vessels have huge defects.

CASE SUMMARY

Herein, we have reported the case of a 26-year-old patient with hepatic AE in an autologous liver graft who underwent complex inferior vena cava (IVC) reconstruction using disease-free IVC, autologous portal vein fragments, and umbilical vein within the ligamentum teres hepatis. The patient showed good surgical recovery without vascular-related complications during the long-term follow-up.

CONCLUSION

We reviewed three studies that have reported complex revascularization of the IVC. This case report and systematic review showed that the use of autologous perihepatic vessels prevents donor-area trauma, immune rejection, and other adverse reactions. When the blood vessel is severely invaded and a single vascular material cannot repair and reconstruct the defect, ELRA may provide a safe and feasible surgical approach, which has good prospects for clinical application.

In situ reconstruction of vascular inflow/outflow to left lateral liver section, ex-vivo liver resection and autologous liver transplantation of remaining liver remnant for hepatic alveolar echinococcosis

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Advanced HAE treated with the modified technique of ex vivo liver resection and autologous liver transplantation.

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The in situ reconstruction of the vascular inflow/outflow of left lateral liver section maintained the PV circulation.

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The subsequent autologous right liver transplantation provided additional liver functional tissues, thus reduced the risk of liver failure.

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This surgical procedure did not require any veno-venous bypass.

Objective

This is a case report on a patient with advanced hepatic alveolar echinococcosis (HAE) treated with autologous liver transplantation without any veno-venous bypass using the modified technique of ex vivo liver resection and autologous liver transplantation (the ERAT technique).

Method

A 27-year old male with advanced HAE underwent in situ reconstruction of vascular inflow/outflow to left lateral liver section, ex-vivo liver resection and autologous liver transplantation of remaining liver remnant (the modified ERAT technique). The operation consisted of hepatotomy along the right border of the falciform ligament, reconstruction of portal vein supplying the left lateral liver section, reconstruction of left hepatic vein, followed by removal of liver segments S1, S4 to S8, ex vivo resection of all involved tissues within these liver segments in the liver remnant, and autologous liver transplantation of the resected liver remnant. The whole surgical procedure lasted for 12 h, and the blood lost was 800 mL. The patient recovered uneventfully in the post-operation period.

Conclusion

The in situ reconstruction of the vascular inflow/outflow of left lateral liver section maintained the PV circulation and provided liver functional support during the operation. The subsequent autologous liver transplantation provided additional liver functional tissues, thus reduced the risk of post-hepatectomy liver failure. This surgical procedure did not require any veno-venous bypass.

Percutaneous stenting of left hepatic vein followed by Ex vivo Liver Resection and Autotransplantation in a patient with hepatic alveolar echinococcosis with Budd-Chiari syndrome

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A metal mesh stent was placed in the left hepatic vein of a 45-year-old man who presented with Budd-Chiari syndrome in stage 1.

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After disappearance of ascites and improvement in liver function, ELRA was performed in stage 2.

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Follow-up examination at 6 months showed normal liver function and no evidence of recurrence.

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In selected patients with Budd-Chiari syndreme, percutaneous stenting followed by ELRA represent an curative treatment option.

Background and aims

Infiltration of hepatic venous outflow in hepatic alveolar echinococcosis can lead to development of Budd-Chiari syndrome. Medical treatment of this condition is generally unsatisfactory. Radical hepatic resection is impossible for extensive parasitic involvement of liver. This is a case report on a patient who was successfully treated with percutaneous stenting of left hepatic vein followed by Ex vivo Liver Resection and Autotransplantation (ELRA).

Methods

Using the transjugular approach, a metal mesh stent was placed in the left hepatic vein of a 45-year-old man who presented with Budd-Chiari syndrome. After disappearance of ascites and improvement in liver function, Ex vivo Liver Resection and Autotransplantation were performed.

Results

The patient underwent left hepatic vein stenting for Budd-Chiari syndrome without complication. Three months later, liver biopsy showed fibrous proliferation of interlobular portal areas and normal hepatic lobules. After successful Ex vivo Liver Resection and Autotransplantation, follow-up examination at 6 months showed normal liver function and no evidence of recurrence.

Conclusions

Allotransplantation is an accepted treatment for advanced hepatic alveolar echinococcosis with Budd-Chiari syndrome. However, shortage of organ donors and need for immunosuppression are challenging problems. In selected patients with hepatic vein stenoses presenting as Budd-Chiari syndreme, percutaneous stenting of hepatic veins followed by ex vivo liver resection and autotransplantation represent an alternative curative treatment option.

A new treatment strategy for end-stage hepatic alveolar echinococcosis: IVC resection without reconstruction

Patients with hepatic alveolar echinococcosis (HAE) infringing on the inferior vena cava (IVC) have a poor prognosis when radical resection cannot be performed because curative resection is limited by IVC reconstruction. There is little information concerning combined resection of the liver and the IVC. This study explored a novel treatment method for HAE infringing on the IVC and evaluated the safety and feasibility of combined resection of the liver and the IVC. A total of 13 patients were treated with liver resection combined with IVC resection for end-stage HAE between January 2016 and July 2018 at the Affiliated Hospital of Qinghai University. The demographic, clinical, and follow-up data were collected and analysed. The 13 patients underwent resection of the IVC without reconstruction. Of these, 3 exhibited oedema of both lower limbs and the scrotum (23.1%), 2 exhibited pneumothorax (15.4%), 1 exhibited bile leakage (7.7%), 1 exhibited bacteraemia (7.7%), and 1 developed abdominal haemorrhage that was stopped with conservative treatment (7.7%). There was 1 case of operation-related mortality because of upper gastrointestinal haemorrhage (7.7%), and no patients developed recurrence or had residual lesions. Liver resection combined with IVC resection is effective and feasible for patients with HAE infringing on the IVC.

Subcutaneous Inoculation of Echinococcus multilocularis Induces Delayed Regeneration after Partial Hepatectomy

Alveolar echinococcosis (AE) is caused by the larval stage of echinococcus multilocularis (E. multilocularis), and hepatectomy is the main modality in hepatic AE patients. Liver regeneration after partial hepatectomy (PHx) in such patients is challenging, and further investigation is needed. Thus far, knowledge regarding the possible impact of E. multilocularis on liver regeneration after PHx is limited. Herein, a subcutaneous infection model of E. multilocularis was developed in C57 BL/6 mice, and after 3 months, PHx was performed. Plasma and liver samples were harvested under inhalational isofluorane (2%) anaesthesia at designated post-PHx time points (0, 24, 48, 96 and 168 h). The parameters included the future remnant liver/body weight ratio (FLR/BW), liver function tests (AST and ALT) and related cytokines (TNF-α, IL-6, Factor V, HMGB1, TGF-β, TSP-1, and TLR4) and proteins (MyD88 and STAT3). To assess the proliferation intensity of hepatocytes, BrdU, Ki67 and PAS staining were carried out in regenerated liver tissue. The FLR/BW in the infected group from 48 h after surgery was lower than that in the control group. The BrdU positive hepatocyte proportions reached their peak at 48 h in the control group and 96 h in the infected group and then gradually decreased. During the first 48 h after surgery, both the AST and ALT levels in the infected group were lower; however, these levels were altered from 96 h after surgery. In the infected group, the concentrations and mRNA expression levels of the pre-inflammatory cytokines TNF-α and IL-6 demonstrated a delayed peak. Moreover, post-operatively, the TGF-β and TSP-1 levels showed high levels in the infected group at each different time-point compared to those in the control group; however, high levels of TGF-β were observed at 96 h in the control group. The MyD88 and STAT3 protein expression levels in the infected group were markedly higher than those in the control group 96 h after surgery. Delayed liver regeneration after PHx was observed in the C57 BL/6 mice with the subcutaneous infection of E. multilocularis in the current study. This phenomenon could be partially explained by the alteration in the pro-inflammatory cytokines in the immunotolerant milieu induced by chronic E. multilocularis infection.

Combined resection of the right liver lobe and retrohepatic inferior vena cava to treat hepatic alveolar echinococcosis: A case report

RATIONALE

Hepatic alveolar echinococcosis (HAE) is a potentially fatal and chronically progressive infestation that is caused by the multivesicular metacestode of Echinococcus multilocularis (EM). HAE behaves like a malignant tumor and has been referred to as "worm cancer." The main treatment method for HAE is surgical resection.

PATIENT CONCERNS

We present a 41-year-old Tibetan alveolar echinococcosis (AE) patient with AE lesions invading the right liver lobe and retrohepatic inferior vena cava (RHIVC).

DIAGNOSES

The patient was diagnosed with HAE based on results obtained from ultrasound examination, computed tomography, liver 3-dimensional reconstruction, serology tests, clinical presentation, and surgical exploration. The final pathology report confirmed the diagnosis as HAE.

INTERVENTIONS

A radical surgery that combined resection of the liver and RHIVC was performed successfully.

OUTCOMES

The patient had an uneventful postoperative recovery and a good prognosis.

LESSONS

When lesions of the liver significantly violate the RHIVC, resecting the RHIVC without reconstruction may be considered if possible.