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Fard-Aghaie MH, Laengle J, Wagner KC, Reese T, Wirtz S, Oldhafer KJ. Liver surgery in the 2020s: ante-situm and in-situ resection are still indicated - A single-center study. HPB (Oxford) 2023; 25:1030-1039. [PMID: 37328365 DOI: 10.1016/j.hpb.2023.05.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/13/2023] [Accepted: 05/27/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Tumor infiltration of the hepatic outflow comprising all three hepatic veins and the inferior vena cava remains a surgical challenge. Liver resection under total vascular exclusion with or without extracorporeal bypass has been described as a therapeutic option for these tumors. Here, we present our experience with these complex surgical methods. METHODS We searched our database for patients treated with an in-situ or ante-situm liver resection (ISR and ASR, respectively) with extracorporeal bypass. We collected demographic and perioperative data. RESULTS From January 2010 to December 2021, we performed 2122 liver resections. Nine patients were treated with ASR and five were treated with ISR. Out of these 14 patients, six had colorectal liver metastases, six had cholangiocarcinoma, and two had non-colorectal liver metastases. The median operative time and bypass time in all patients were 536.5 and 150 min, respectively. Compared with ISR, ASR required a longer operative time (ASR 586 min and ISR 495 min) and a longer bypass time (ASR 155 min and ISR 122 min). Morbidity (Clavien-Dindo grade > 3A adverse events) occurred in 78.5% of patients. 90-day postoperative mortality was 7%. Median overall survival was 33 months. Seven patients experienced recurrence. In these patients, median disease-free survival was 9 months. CONCLUSION Resection of tumors infiltrating the hepatic outflow poses a high risk for patients. However, with rigorous selection and an experienced perioperative team, these patients can be treated surgically with reasonable oncological outcomes.
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Affiliation(s)
- Mohammad H Fard-Aghaie
- Asklepios Hospital Barmbek, Department of Surgery, Division of HBP Surgery, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Johannes Laengle
- Asklepios Hospital Barmbek, Department of Surgery, Division of HBP Surgery, Semmelweis University Campus Hamburg, Hamburg, Germany; Division of Visceral Surgery, Department of General Surgery, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Kim C Wagner
- Asklepios Hospital Barmbek, Department of Surgery, Division of HBP Surgery, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Tim Reese
- Asklepios Hospital Barmbek, Department of Surgery, Division of HBP Surgery, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Sebastian Wirtz
- Asklepios Hospital Barmbek, Department of Anesthesiology, Hamburg, Germany
| | - Karl J Oldhafer
- Asklepios Hospital Barmbek, Department of Surgery, Division of HBP Surgery, Semmelweis University Campus Hamburg, Hamburg, Germany.
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Zhou Y, Wu L, Xu D, Wan T, Si X. A pooled analysis of combined liver and inferior vena cava resection for hepatic malignancy. HPB (Oxford) 2017. [PMID: 28645571 DOI: 10.1016/j.hpb.2017.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Limited data are currently available to address the safety and efficacy of combined resection of the liver and inferior vena cava (IVC) for hepatic malignancies. METHODS A systematic review was performed to identify relevant studies. Pooled individual data were examined for the clinical outcome of combined resection of the liver and IVC for hepatic malignancies. RESULTS A total of 258 patients were described in 38 articles eligible for inclusion. Resections were performed for colorectal liver metastasis (CLM) [n = 128 (50%)], intrahepatic cholangiocarcinoma (ICC) [n = 51 (20%)], hepatocellular carcinoma (HCC) [n = 48 (19%)], and other pathologies [n = 31 (11%)]. There were 14 (5%) perioperative deaths. The median survival duration was 34 months, and the 1-, 3- and 5-year overall survival (OS) rate was 79%, 46% and 33%, respectively. The 5-year OS rate was 26% for CLM, 37% for ICC, and 30% for HCC. CONCLUSION Combined resection of the liver and IVC for hepatic malignancies is safe and applicable, and offers acceptable survival outcomes.
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Affiliation(s)
- Yanming Zhou
- Department of Hepatobiliary & Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China.
| | - Lupeng Wu
- Department of Hepatobiliary & Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Dong Xu
- Department of Hepatobiliary & Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Tao Wan
- Department of Hepatobiliary & Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Xiaoying Si
- Department of Hepatobiliary & Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China
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Kasai Y, Hatano E, Seo S, Taura K, Yasuchika K, Okajima H, Kaido T, Uemoto S. Proposal of selection criteria for operative resection of hepatocellular carcinoma with inferior vena cava tumor thrombus incorporating hepatic arterial infusion chemotherapy. Surgery 2017; 162:742-751. [PMID: 28705491 DOI: 10.1016/j.surg.2017.05.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/01/2017] [Accepted: 05/10/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Because operative resection of hepatocellular carcinoma with inferior vena cava tumor thrombus has been associated with a substantial risk of recurrence and postoperative morbidity, adequate patient selection for resection is necessary. Our aim was to propose selection criteria for resection of hepatocellular carcinoma with inferior vena cava tumor thrombus. METHODS Long-term outcomes were analyzed retrospectively in 39 operative cases of hepatocellular carcinoma with inferior vena cava tumor thrombus (1996-2015). Since 2003, preoperative hepatic arterial infusion chemotherapy instead of immediate resection has been performed in patients with advanced inferior vena cava tumor thrombus, defined as those patients with suspected extrahepatic metastasis, who will need extracorporeal circulation, or who have marginal liver function and/or multiple bilobar tumors. Indication for resection has been based on the tumor response to hepatic arterial infusion chemotherapy thereafter. RESULTS The median survival time for all patients was 15.2 months. Multivariate analysis revealed that preoperative hepatic arterial infusion chemotherapy (hazard ratio: 0.30), use of extracorporeal circulation (3.12), and extrahepatic metastasis (2.67) were independent prognostic factors for overall survival. Among patients with initially advanced inferior vena cava tumor thrombus, preoperative hepatic arterial infusion chemotherapy was associated with a much more favorable prognosis compared with no hepatic arterial infusion chemotherapy (median survival time: unreached vs 8.3 months, P = .007). Overall survival was significantly worse in patients with uncontrolled, advanced inferior vena cava tumor thrombus than in those without advanced inferior vena cava tumor thrombus or with advanced inferior vena cava tumor thrombus controlled by preoperative hepatic arterial infusion chemotherapy (median survival time: 10.4 vs 26.1 months, P = .039). CONCLUSION An effective response to hepatic arterial infusion chemotherapy and subsequent operative resection salvaged patients with initially advanced inferior vena cava tumor thrombus. Our results suggest that operative resection should be indicated only in patients without advanced inferior vena cava tumor thrombus or with advanced inferior vena cava tumor thrombus controlled by preoperative hepatic arterial infusion chemotherapy.
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Affiliation(s)
- Yosuke Kasai
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Etsuro Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan.
| | - Satoru Seo
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kojiro Taura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kentaro Yasuchika
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshimi Kaido
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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4
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Shinkai M, Mochizuki K, Kitagawa N, Take H, Usui H, Yamoto KN, Fujita S, Ohhama Y. Usefulness of a recanalized umbilical vein for vascular reconstruction in pediatric hepatic surgery. Pediatr Surg Int 2016; 32:553-8. [PMID: 27083897 DOI: 10.1007/s00383-016-3893-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE Pediatric surgeons currently engage in various abdominal vascular surgeries, which sometimes require vascular conduits or grafts. Herein, we report our experience with patients undergoing vascular reconstruction using a recanalized umbilical vein (rUV) and their long-term outcome. METHOD Five patients with extrahepatic portal vein obstruction (EHPVO) underwent mesenterico-/porto-left portal vein (PV) bypass surgery using a short rUV conduit with an interposition vein graft. A sixth neonate with a huge hepatic tumor underwent PV reconstruction with anastomosis of rUV to the proximal PV stump following right hepatectomy with partial PV resection. A seventh patient underwent living donor liver transplantation for recurrent hepatoblastoma. The hepatic inferior vena cava (IVC) was resected because of tumor involvement and reconstructed by transposition of the infrahepatic IVC and interposition of rUV obtained from the donor liver graft. RESULTS Sufficient flow through rUV was achieved and maintained in all patients without any complications during follow-up (0.7-6.9 years). Esophageal varices, splenomegaly, and other laboratory test abnormalities because of portal hypertension disappeared after surgery in patients with EHPVO. CONCLUSION Our experience confirmed the usefulness and long-term patency of rUV as an entry to the intrahepatic PV and as a free vascular graft to reconstruct PV or IVC.
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Affiliation(s)
- Masato Shinkai
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan.
| | - Kyoko Mochizuki
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Norihiko Kitagawa
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Hiroshi Take
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Hidehito Usui
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Kaori Nakamura Yamoto
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Shogo Fujita
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
| | - Youkatsu Ohhama
- Department of Surgery, Kanagawa Children's Medical Center, 138-4 Mutsukawa 2-chome, Minami-ku, Yokohama, 232-8555, Japan
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Complex Liver Resection Using Standard Total Vascular Exclusion, Venovenous Bypass, and In Situ Hypothermic Portal Perfusion. Ann Surg 2015; 262:93-104. [DOI: 10.1097/sla.0000000000000787] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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6
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Azoulay D, Pascal G, Salloum C, Adam R, Castaing D, Tranecol N. Vascular reconstruction combined with liver resection for malignant tumours. Br J Surg 2014; 100:1764-75. [PMID: 24227362 DOI: 10.1002/bjs.9295] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND The resectability criteria for malignant liver tumours have expanded during the past two decades. The use of vascular reconstruction after hepatectomy has been integral in this process. However, the majority of reports are anecdotal. This is a retrospective analysis of the techniques, morbidity, mortality and risk factors of liver resections with vascular reconstruction based on a large series from a single centre. METHODS Patients who underwent hepatic resection combined with vascular resection and reconstruction between 1997 and 2009 were included in this study. Indications for surgery, morbidity and 90-day mortality are reported along with factors predictive of operative mortality. RESULTS Eighty-four patients had liver resection with 97 vascular resections and reconstruction. There were 44 men and 40 women with a mean(s.d.) age of 56·9(12·1) years. Mean(s.d.) follow-up was 37·3(34·1) months. All patients had primary or metastatic liver tumours. The perioperative morbidity rate was 62 per cent (52 patients) and the operative mortality rate 14 per cent (12). Predictors of operative mortality were: bilirubin level exceeding 34 µmol/ml (P = 0·023), indocyanine green retention rate at 15 min over 10 per cent (P = 0·031), duration of ischaemia (P = 0·011), amount of blood transfused (P = 0·025) and combined major extrahepatic procedure (P = 0·042). Actuarial 3- and 5-year survival rates were 44 and 26 per cent respectively. CONCLUSION Liver resection with combined vascular resection and reconstruction can be performed in selected patients with acceptable morbidity and mortality. The lack of therapeutic alternatives and the poor outcome of non-operative management seem to justify this approach. The identification of risk factors should help improve patient selection and postoperative outcome as well as facilitate objective risk communication with surgical candidates.
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Affiliation(s)
- D Azoulay
- Centre Hépato-Biliaire, Département de Chirurgie Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris (AP-HP) Hôpital Paul Brousse, Villejuif; Service de Chirurgie Hépato-Bilio-Pancreatique, AP-HP Hôpital Henri Mondor, Créteil, France
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Hepatobiliary resection with concomitant resection of the inferior vena cava for advanced intrahepatic cholangiocarcinoma: report of a case. Surg Today 2012; 43:1321-5. [DOI: 10.1007/s00595-012-0319-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 05/17/2012] [Indexed: 10/27/2022]
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8
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Yamamoto Y. Ante-situm hepatic resection for tumors involving the confluence of hepatic veins and IVC. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2012; 20:313-23. [DOI: 10.1007/s00534-012-0525-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Yuzo Yamamoto
- Department of Gastroenterological Surgery; Akita University Graduate School of Medicine; 1-1-1 Hondo Akita 010-8543 Japan
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9
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Malde DJ, Khan A, Prasad KR, Toogood GJ, Lodge JPA. Inferior vena cava resection with hepatectomy: challenging but justified. HPB (Oxford) 2011; 13:802-10. [PMID: 21999594 PMCID: PMC3238015 DOI: 10.1111/j.1477-2574.2011.00364.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 06/19/2011] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the clinical outcome of hepatectomy combined with inferior vena cava (IVC) resection and reconstruction for treatment of invasive liver tumours. METHODS From February 1995 to September 2010, 2146 patients underwent liver resections in our hospital's hepatopancreatobiliary unit. Of these, 35 (1.6%) patients underwent hepatectomy with IVC resection. These patients were included in this study. Data were analysed from a prospectively collected database. RESULTS Resections were carried out for colorectal liver metastasis (CRLM) (n= 21), hepatocellular carcinoma (n= 6), cholangiocarcinoma (n= 3) and other conditions (n= 5). Resections were carried out with total vascular occlusion in 34 patients and without in one patient. In situ hypothermic perfusion was performed in 13 patients; the ante situm technique was used in three patients, and ex vivo resection was used in six patients. There were four early deaths from multiple organ failure. Postoperative complications occurred in 14 patients, three of whom required re-operation. Median overall survival was 29 months and cumulative 5-year survival was 37.7%. Rates of 1-, 2- and 5-year survival were 75.9%, 58.7% and 19.6%, respectively, in CRLM patients. CONCLUSIONS Aggressive surgical management of liver tumours with IVC involvement offers the only hope for cure in selected patients. Resection by specialist teams affords acceptable perioperative morbidity and mortality rates.
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Affiliation(s)
- Deep J Malde
- Hepatopancreatobiliary and Transplant Unit, St James University Hospital, Leeds, UK
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10
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Hashimoto T, Minagawa M, Aoki T, Hasegawa K, Sano K, Imamura H, Sugawara Y, Makuuchi M, Kokudo N. Caval invasion by liver tumor is limited. J Am Coll Surg 2008; 207:383-92. [PMID: 18722944 DOI: 10.1016/j.jamcollsurg.2008.02.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2007] [Accepted: 02/19/2008] [Indexed: 12/22/2022]
Abstract
BACKGROUND Successful hepatic resection with combined inferior vena cava (IVC) resection has been reported. The necessity of a combined IVC resection for hepatic malignancies that have attached to the IVC has not been fully evaluated. STUDY DESIGN In this retrospective study, 162 lesions for which preoperative CT findings suggested attachment to the IVC were evaluated. Patient survival rates were examined according to type of tumor and the operative procedure. For adenocarcinoma lesions, several CT findings, including extent of the IVC circumference attached to the tumor compared with the whole IVC circumference (E(IVC)), were evaluated in conjunction with IVC resection. RESULTS Among 162 lesions, 18 adenocarcinoma lesions were resected in combination with an IVC resection. Histologic IVC invasion was confirmed in eight patients. None of the 67 hepatocellular carcinoma lesions required concomitant IVC resection. Overall 5-year survival rate of the patients who underwent concomitant liver and IVC resections was 33.1%. Among the adenocarcinoma lesions, the positive predictive factors for IVC resection were an E(IVC) value > 25% and a peaked deformity of the IVC wall, according to a multivariate analysis. CONCLUSIONS Most hepatic malignancies attached to the IVC wall can be completely removed without IVC resection. E(IVC) and deformity of the IVC on CT can be useful indicators for a concomitant liver and IVC resection. Careful separation of the liver and IVC is a key point for minimizing the size of the resected IVC and to avoid unnecessary IVC resection.
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Affiliation(s)
- Takuya Hashimoto
- Department of Hepato-Biliary-Pancreatic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Sugawara Y, Tamura S. Reconstructing the drainage vein of the right paramedian sector in right liver grafts. Liver Transpl 2007; 13:1075-7. [PMID: 17663402 DOI: 10.1002/lt.21238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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12
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Shimoda M, Marubashi S, Dono K, Miyamoto A, Takeda Y, Nagano H, Umeshita K, Monden M. Utilization of autologous vein graft for replacement of the inferior vena cava in living-donor liver transplantation for obliterative hepatocavopathy. Transpl Int 2007; 20:804-7. [PMID: 17623051 DOI: 10.1111/j.1432-2277.2007.00519.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Obliterative hepatocavopathy (OHC) is a subtype of Budd-Chiari syndrome in which stenosis or obstruction of the retrohepatic inferior vena cava (IVC) is observed. Although IVC replacement is necessary in OHC patients, there are hardly any graft vessels available for IVC reconstruction during living-donor liver transplantation (LDLT). Here, we describe a novel technique of IVC reconstruction using only the autologous blood vessels in an OHC patient during LDLT. In this case, sufficient drainage of the hepatic outflow and reconstruction of the venous return from the lower half of the body were simultaneously required. Therefore, we substituted the retrohepatic IVC with the suprarenal IVC of the recipient, and we reconstructed the IVC continuity by using the autologous internal jugular vein and external iliac vein. The operation was safe, and the postoperative venous drainage from the hepatic tributaries was in good condition. This procedure might be an option for IVC replacement during LDLT.
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Affiliation(s)
- Masafumi Shimoda
- Department of Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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13
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Azoulay D, Andreani P, Maggi U, Salloum C, Perdigao F, Sebagh M, Lemoine A, Adam R, Castaing D. Combined liver resection and reconstruction of the supra-renal vena cava: the Paul Brousse experience. Ann Surg 2006; 244:80-8. [PMID: 16794392 PMCID: PMC1570596 DOI: 10.1097/01.sla.0000218092.83675.bc] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Liver tumors with inferior vena cava (IVC) involvement may require combined resection of the liver and IVC. This approach, with its high surgical risks and poor long-term prognosis, was precluded until the development of neoadjuvant chemotherapy, portal vein embolization, reinforced vascular prostheses, and technical advances in liver transplantation. METHODS We reviewed 22 cases of hepatectomy with retrohepatic IVC resection and reconstruction. The patients had a median age of 51.5 years (range, 32.8-75.3 years). Indications for resection were: liver metastases (n = 9), cholangiocarcinoma (n = 8), hepatocellular carcinoma (n = 2), other cancers (n = 3). The liver resections carried out included 18 first, 3 second, and one third hepatectomy. Segment 1 (caudate lobe) was included in the specimen in 19 cases (86%). Resection concerned 1 to 6 liver segments (median = 5.0). Vascular control was achieved by vascular exclusion of the liver preserving the caval flow (n = 1), standard vascular exclusion of the liver (n = 12), in situ cold perfusion of the liver (n = 9). Ex situ surgery was not necessary in any case. Venovenous bypass was used in 12 cases. The IVC was reconstructed with a ringed Gore-Tex tube graft (n = 10), primarily (n = 8), or by caval plasty (n = 4). A main hepatic vein was reimplanted in 6 cases: into the native IVC (n = 4) or into a Gore-Tex tube graft (n = 2). RESULTS One patient died (4.5%) due to catheter infection, 7 days after in situ cold perfusion with replacement of the vena cava. Eight patients (36%) had no complications and 14 patients (64%) had 23 complications. In all but 1 case, the complications were transient and successfully controlled. The patients stayed in intensive care for 3.3 +/- 2.0 days and in the hospital for 17.7 +/- 7.8 days. All vascular reconstructions were patent at last follow-up. With median follow-up of 19 months, 10 patients died of tumor recurrence and eleven were alive with (n = 5) or without (n = 6) disease. Actuarial 1-, 3-, and 5-year survival rates were 81.8%, 38.3%, and 38.3%, respectively. CONCLUSIONS IVC resection and reconstruction combined with liver resection can be safely performed in selected patients. The lack of alternative treatments and the spontaneous poor prognosis justify this approach, provided that surgery is carried out at a center specialized in both liver surgery and liver transplantation. The development of adjuvant chemotherapy regimens is required to improve the long-term results of this salvage surgery.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France.
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14
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Aoki T, Sugawara Y, Imamura H, Seyama Y, Minagawa M, Hasegawa K, Kokudo N, Makuuchi M. Hepatic resection with reconstruction of the inferior vena cava or hepatic venous confluence for metastatic liver tumor from colorectal cancer. J Am Coll Surg 2004; 198:366-72. [PMID: 14992737 DOI: 10.1016/j.jamcollsurg.2003.11.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2003] [Revised: 11/03/2003] [Accepted: 11/04/2003] [Indexed: 12/12/2022]
Abstract
BACKGROUND Resection of colorectal liver metastases infiltrating the inferior vena cava (IVC) or hepatic venous confluence (HVC) is technically feasible, but the procedure frequently involves invasive techniques, and its long-term outcome has not yet been fully described. STUDY DESIGN From October 1994 through June 2001, 87 patients underwent first curative hepatic resections for colorectal metastases. Nine patients (the IVC/HVC group) received hepatectomy combined with IVC or HVC reconstruction. Clinicopathologic characteristics, surgical results, and patient survival were investigated and compared with those of the remaining 78 patients (the comparison group). RESULTS Three IVCs and eight hepatic veins were successfully resected and reconstructed by primary closure (n = 3), direct anastomosis (n = 1), or by the use of autologous vein grafts (n = 7). A comparison between the two groups revealed that the primary colorectal tumor stage was similar, but the IVC/HVC group had more (median 4 versus 2, p < 0.05) and larger (median 5.0 versus 3.2 cm, p < 0.05) lesions. The IVC/HVC group required longer operating times (median 600 versus 320 minutes, p < 0.001) and suffered greater blood loss (median 1,034 versus 434 g, p < 0.01) and more extensive liver parenchyma resection (median 585 versus 155 g, p < 0.001). Patients in the IVC/HVC group had a shorter survival time (median survival time 25.8 versus 44.0 months, p < 0.01). CONCLUSIONS Hepatic resection combined with the IVC or HVC reconstruction for colorectal liver metastases can be performed with acceptable morbidity, and possibly with no mortality. Although no definite conclusion on long-term survival can be drawn from our study, given the limited number of patients, their overall survival was unsatisfactory. Further studies are needed to clarify the contribution of combined resection and reconstruction of IVC/HVC to long-term survival, because surgical resection currently provides the only hope of cure.
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Affiliation(s)
- Taku Aoki
- Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Arii S, Teramoto K, Kawamura T, Takamatsu S, Sato E, Nakamura N, Iwai T, Mori A, Tanaka J, Imamura M. Significance of hepatic resection combined with inferior vena cava resection and its reconstruction with expanded polytetrafluoroethylene for treatment of liver tumors. J Am Coll Surg 2003; 196:243-9. [PMID: 12595053 DOI: 10.1016/s1072-7515(02)01616-2] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Resection of the IVC is required when a liver tumor invading the IVC is completely removed. The purpose of this study was to evaluate the clinical significance of hepatectomy combined with IVC resection and reconstruction with an ePTFE graft for treatment of invasive liver tumors and to discuss the validity of this surgery. STUDY DESIGN Eleven selected patients with liver tumors underwent various types of hepatectomy with retrohepatic IVC resection, followed by IVC reconstruction. The postoperative courses, clinicopathologic features of the tumors, operative procedures, and outcomes of the patients were studied. RESULTS Ten of 11 patients did not require an active ventriculovenous bypass using a biopump. Invasion to the IVC was histologically proved in 9 of the 11 patients. After reconstruction, all artificial vessel grafts maintained patency throughout the observation period. Four patients are still alive with cancer-free status ranging from approximately 11 years to 5 months. One-year, 3-year, and 5-year survival rates were 63.6%, 38.2%, and 25.5%, respectively, with a 50% survival of 29 months. CONCLUSIONS IVC resection and its reconstruction with ePTFE for treatment of liver tumors was safely performed on 11 selected patients with a 50% survival of 29 months. Patency of the graft was maintained for the longterm without infectious complications. This surgical procedure is indicated in some select patients in whom IVC invasion is extensive.
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Affiliation(s)
- Shigeki Arii
- Department of Surgery, Tokyo Medical and Dental University, Tokyo, Japan
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Lechaux D, Megevand JM, Raoul JL, Boudjema K. Ex vivo right trisegmentectomy with reconstruction of inferior vena cava and "flop" reimplantation. J Am Coll Surg 2002; 194:842-5. [PMID: 12081078 DOI: 10.1016/s1072-7515(02)01169-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- David Lechaux
- Départment de Chirurgie Viscérale, Centre Hospitalier Universitaire de Rennes, Hopital Pontchaillou, France
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