Major hepatic resection using vascular isolation and hypothermic perfusion

A contemporary view on vascular resections and reconstruction during hepatectomies

Oncological hepatic surgery carries the possibility to perform vascular reconstructions for advanced tumours with vessel invasion since surgery often represents the only potentially curative approach for these tumours. An extended review was conducted in an attempt to understand and clarify the latest trends in hepatectomies with vascular resections. We searched bibliographic databases including PubMed, Scopus, references from bibliographies and Cochrane Library. Information and outcomes from worldwide clinical trials were collected from qualified institutions performing hepatectomies with vascular resection and reconstruction. Careful patient selection and thorough preoperative imaging remain crucial for correct and safe surgical planning. A literature analysis shows that vascular resections carry different indications in different diseases. Despite significant advances made in imaging techniques and technical skills, reports of hepatectomies with vascular resections are still associated with high postoperative morbidity and mortality. The trend of complex liver resection with vascular resection is constantly on the increase, but more profound knowledge as well as further trials are required. Recent technological developments in multiple fields could surely provide novel approaches and enhance a new era of digital imaging and intelligent hepatic surgery.

Liver resection with two-step vascular exclusion, in situ hypothermic portal perfusion for the treatment of end-stage hepatic alveolar echinococcosis

PURPOSE

To evaluate the safety and efficacy of two-step vascular exclusion and in situ hypothermic portal perfusion in patients with end-stage hepatic hydatidosis.

METHODS

This study involved patients with advanced hepatic hydatid disease undergoing surgical treatment between 2022 and 2023, which included resection and reconstruction of the hepatic veins, inferior vena cava (IVC), and portal vein (PV). We described the technical details of liver resection and vascular reconstruction, as well as the use of two-step vascular exclusion and in situ hypothermic portal perfusion techniques during the vascular reconstruction process.

RESULT

We included 7 patients with advanced hepatic hydatid disease who underwent surgical resection using two-step vascular exclusion and in situ hypothermic portal perfusion. The mean duration of surgery was 12.5 h (range, 7.5-15.0 h). The average hepatic ischemia time was 45 min (range, 25-77 min), while the occlusion time of the IVC was 87 min (range, 72-105 min). The total blood loss was 1000 milliliters (range, 500-1250 milliliters). Postoperatively, patients exhibited good recovery of liver and renal function. The mean ICU stay was 2 days (range, 1-3 days), and the mean postoperative hospital stay was 13 days (range, 9-16 days), with no Grade III or above complications observed during a mean follow-up period of 15 months (range, 9-24 months), CONCLUSION: two-step vascular exclusion and in situ hypothermic portal perfusion for surgical resection of end-stage hepatic hydatid disease is safe and effective. This significantly reduces the anhepatic time.

Liver surgery in the 2020s: ante-situm and in-situ resection are still indicated - A single-center study

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.

Future liver remnant augmentation preceding ex vivo hepatectomy with IVC replacement: a strategy to achieve R0 margins

PURPOSE

Ex vivo hepatectomy with autotransplantation (EHAT) provides opportunity for R0 resection. As EHAT outcomes after future liver remnant (FLR) augmentation techniques are not well documented, we examine results of EHAT after augmentation for malignant tumors.

METHODS

Retrospective analysis of six cases of EHAT was performed. Of these, four occurred after preoperative FLR augmentation between 2018 and 2022.

RESULTS

Six patients were offered EHAT of 26 potential candidates. Indications for resection were involvement of hepatic vein outflow and inferior vena cava (IVC) with metastatic colorectal carcinoma (n = 3), cholangiocarcinoma (n = 2), or leiomyosarcoma (n = 1). Five patients were treated with neoadjuvant chemotherapy and four had preoperative liver augmentation. One hundred percent of cases achieved R0 resection. Of the augmented cases, three patients are alive after median follow-up of 28 months. Postoperative mortality due to liver failure was 25% (n = 1).

CONCLUSIONS

For select patients with locally advanced tumors involving all hepatic veins and the IVC for whom conventional resection is not an option, EHAT provides opportunity for R0 resection. In addition, in patients with inadequate FLR volume, further operative candidacy with acceptable results can be achieved by combined liver augmentation techniques. To better characterize outcomes in this small subset, a registry is needed.

Pushing the Limits of Surgical Resection in Colorectal Liver Metastasis: How Far Can We Go?

Colorectal cancer is the third most common cancer worldwide, and up to 50% of all patients diagnosed will develop metastatic disease. Management of colorectal liver metastases (CRLM) has been constantly improving, aided by newer and more effective chemotherapy agents and the use of multidisciplinary teams. However, the only curative treatment remains surgical resection of the CRLM. Although survival for surgically resected patients has shown modest improvement, this is mostly because of the fact that what is constantly evolving is the indication for resection. Surgeons are constantly pushing the limits of what is considered resectable or not, thus enhancing and enlarging the pool of patients who can be potentially benefited and even cured with aggressive surgical procedures. There are a variety of procedures that have been developed, which range from procedures to stimulate hepatic growth, such as portal vein embolization, two-staged hepatectomy, or the association of both, to technically challenging procedures such as simultaneous approaches for synchronous metastasis, ex-vivo or in-situ perfusion with total vascular exclusion, or even liver transplant. This article reviewed the major breakthroughs in liver surgery for CRLM, showing how much has changed and what has been achieved in the field of CRLM.

Advances in the management of liver and biliary tumors

Over the past 50 years, the management of liver and biliary tumors has evolved significantly. Initially considered highly morbid and lethal, resection is now the treatment of choice for a significant proportion of patients with malignant and benign hepatobiliary disease. Improved operative/anesthetic techniques, use of parenchymal-sparing approaches, better patient selection for surgery, effective liver-directed therapies, and new insights into tumor biology are significant contributors to our transformed approach to hepatobiliary neoplasms.

Advances in the surgical treatment of liver cancer

Liver resection is the standard curative treatment for liver cancer. Advances in surgical techniques over the last 30 years, including the preoperative assessment of the future liver remnant, have improved the safety of liver resection. In addition, advances in nonsurgical multidisciplinary treatment have increased the opportunities for tumor downstaging. Consequently, the indications for resection of more advanced liver cancer have expanded. Laparoscopic and robot-assisted liver resections have also gradually become more widespread. These techniques should be performed in stages, depending on the difficulty of the procedure. Advances in preoperative simulation and intraoperative navigation technology may have also lowered the threshold for their performance and may have promoted their widespread use. New insights and experiences gained from laparoscopic surgery may be applicable in open surgery. Liver transplantation, which is usually indicated for patients with poor liver function, has also become safer with advances in perioperative management. The indications for liver transplantation in liver cancer are also expanding. Although the coronavirus disease 2019 pandemic has forced the postponement of liver resection and transplantation procedures, liver surgeons should appropriately tailor the surgical plan to the individual patient as part of multidisciplinary treatment. This review may provide an entry point for future clinical research by identifying currently unresolved issues regarding liver cancer, and particularly hepatocellular carcinoma.

Vascular surgery in liver resection

Vascular surgery in liver resection is a standard part of liver transplantation, but is also used in oncological liver surgery. Malignant liver tumors with vascular involvement have a poor prognosis without resection. Surgery is currently the only treatment to provide long-term survival in advanced hepatic malignancy. Even though extended liver resections are increasingly performed, vascular involvement with need of vascular reconstruction is still considered a contraindication for surgery in many institutions. However, vascular resection and reconstruction in liver surgery-despite being complex procedures-are safely performed in specialized centers. The improvements of the postoperative results with reduced postoperative morbidity and mortality are a result of rising surgical and anesthesiological experience and advancements in multimodal treatment concepts with preconditioning measures regarding liver function and systemic treatment options. This review focuses on vascular surgery in oncological liver resections. Even though many surgical techniques were developed and are also used during liver transplantation, this special procedure is not particularly covered within this review article. We provide a summary of vascular reconstruction techniques in oncological liver surgery according to the literature and present also our own experience. We aim to outline the current advances and standards in extended surgical procedures for liver tumors with vascular involvement established in specialized centers, since curative resection improves long-term survival and shifts palliative concepts to curative therapy.

Vascular Involvements in Cholangiocarcinoma: Tips and Tricks

Simple Summary

Cholangiocarcinoma (CCA) is the second most common liver primary malignancy and its gold-standard treatment is surgery. Unfortunately, CCA is seldom amenable to curative resection due to late-stage diagnosis and frequent major vascular invasion. Major vascular invasion has historically been considered a contraindication to resection, but lately aggressive surgeries for CCA with vascular involvement have been shown to improve outcomes. The purpose of this review is to provide a comprehensive and up to date summary of the strategies for CCA resection, focusing on the surgical techniques and results of complex procedures with tumour vascular involvements. The current review shows that satisfactory results can be achieved in patients with CCA and tumoral vascular invasion by aggressive surgical resection and challenging vascular reconstruction, ensuring a meticulous evaluation of patients in a multidisciplinary setting by experienced hepatobiliary surgeons.

Abstract

Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract. To date, surgical treatment remains the only hope for definitive cure of CCA patients. Involvement of major vascular structures was traditionally considered a contraindication for resection. Nowadays, selected cases of CCA with vascular involvement can be successfully approached. Intrahepatic CCA often involves the major hepatic veins or the inferior vena cava and might necessitate complete vascular exclusion, in situ hypothermic perfusion, ex situ surgery and reconstruction with autologous, heterologous or synthetic grafts. Hilar CCA more frequently involves the portal vein and hepatic artery. Resection and reconstruction of the portal vein is now considered a relatively safe and beneficial technique, and it is accepted as a standard option either with direct anastomosis or jump grafts. However, hepatic artery resection remains controversial; despite accumulating positive reports, the procedure remains technically challenging with increased rates of morbidity. When arterial reconstruction is not possible, arterio-portal shunting may offer salvage, while sometimes an efficient collateral system could bypass the need for arterial reconstructions. Keys to achieve success are represented by accurate selection of patients in high-volume referral centres, adequate technical skills and eclectic knowledge of the various possibilities for vascular reconstruction.

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.

The technical aspects of ex vivo hepatectomy with autotransplantation: a systematic review and meta-analysis

PURPOSE

Ex vivo hepatectomy is the incorporation of liver transplant techniques in the non-transplant setting, providing opportunity for locally advanced tumors found conventionally unresectable. Because the procedure is rare and reports in the literature are limited, we sought to perform a systematic review and meta-analysis investigating technical variations of ex vivo hepatectomies.

METHODS

In the literature, there is a split in those performing the procedure between venovenous bypass (VVB) and temporary portacaval shunts (PCS). Of the 253 articles identified on the topic of ex vivo resection, 37 had sufficient data to be included in our review.

RESULTS

The majority of these procedures were performed for hepatic alveolar echinococcosis (69%) followed by primary and secondary hepatic malignancies. In 18 series, VVB was used, and in 18, a temporary PCS was performed. Comparing these two groups, intraoperative variables and morbidity were not statistically different, with a cumulative trend in favor of PCS. Ninety-day mortality was significantly lower in the PCS group compared to the VVB group (p=0.03).

CONCLUSION

In order to better elucidate these differences between technical approaches, a registry and consensus statement are needed.

Outcomes of ex vivo liver resection and autotransplantation: A systematic review and meta-analysis

BACKGROUND

Many patients with hepatic tumors cannot benefit from resection owing to the difficult anatomic sites of their lesions. Some of these patients might be eligible for ex vivo liver resection and autotransplantation. This procedure consists of complete hepatectomy, extracorporeal liver resection, and autotransplantation of the remnant liver.

METHODS

Four databases were searched for studies reporting cases of ex vivo liver resection and autotransplantation. Outcomes of this procedure were evaluated by meta-analysis of proportions with random effects model and individual participant data analysis.

RESULTS

Fifty-three studies were assessed. Meta-analysis revealed an R0 resection rate of 93.4% (95% confidence interval: 81.0-97.9%, I² = 0%), a frequency of major surgical complications of 24.5% (95% confidence interval, 16.9-34.3%, I² = 26%), a 30-day mortality of 9.5% (95% confidence interval: 5.9-14.9%, I² = 0%), and a 1-year survival of 78.4% (95% confidence interval: 62.2-88.8%, I² = 64%). We were able to obtain the individual participant data in 244 patients; R0 resection was achieved in 98.6%, with no obvious difference between analyzed subgroups. The 30-day mortality and 1-year survivals were 7.9% and 82.1%, respectively. For groups with malignant and nonmalignant tumors, the 30-day mortalities were 11.3% vs. 6.3% (P = .181), and 1-year survivals were 65.0% vs. 89.7% (P < .001). When comparing those with malignant versus those with nonmalignant lesions, major surgical complications occurred in 50.0% vs. 21.0%; P < .001). Regression analysis revealed that outcomes of patients with benign tumors were better compared with those with malignant tumors (1-year survival, odds ratio: 4.629; 95% confidence interval: 2.181-10.097, P < .001).

CONCLUSION

Ex vivo liver resection and autotransplantation facilitates radical treatment in selected patients with conventionally unresectable hepatic tumors and normal liver function. The outcomes of treatment of malignant lesions appear to be less satisfactory.

Hypothermic perfusion hepatectomy for unresectable liver cancer: A single-center experience

BACKGROUND

The resection of liver tumors that involve the hepatic veins adjacent to the vena cava or hepatic hilum is technically challenging. We present our surgical techniques and the long-term outcome of five patients with conventionally unresectable tumors.

METHODS

Five patients with conventionally unresectable tumors were successfully treated by "ex-situ liver resection" and "in-situ and ante-situm hypothermic liver perfusion" under total vascular exclusion and venovenous bypass.

RESULTS

These approaches allowed complete tumor removal with vascular reconstruction under a bloodless surgical field, while minimizing hepatic ischemic injury and preserving liver function. No perioperative mortalities occurred, and postoperative complications were minimal. The postoperative survival periods were limited due to the advanced malignancies in our patients, but the survival benefit was encouraging. The median postoperative survival time was 29.1 months, with the longest survival period being nearly 10 years. These approaches improved the quality of life and provided an opportunity for additional treatment.

CONCLUSIONS

Hypothermic perfusion hepatectomy is a realistic option for achieving surgical cure or significantly improved survival and quality of life in patients with tumors deemed unresectable using conventional normothermic hepatectomy. These approaches can overcome the limitations of the liver's restricted normothermic ischemia tolerance or inaccessible tumor locations.

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.

Liver Resection with In Situ Hypothermic Perfusion: An Old but Effective Method

BACKGROUND

More than 40 years ago, patients with tumors infiltrating the confluence of the hepatic veins were deemed unresectable; however, in situ hypothermic perfusion, first described by Fortner et al. (Ann Surg 180(4):644-652, 1974), allowed resection of these tumors. In order to prevent liver ischemia after total vascular exclusion, the liver was flushed with a cooled organ preservation solution. The surgeon was able to resect the tumor and reconstruct the hepatic veins with occlusion of the hepatic inflow and outflow.

METHODS

A 55-year-old female suffering from a leiomyosarcoma of the inferior vena cava (IVC) presented to our clinic. Three years ago, the IVC was replaced with a synthetic graft. During the patient's follow-up, a computed tomography (CT) scan revealed three hepatic metastases of the sarcoma. A central metastasis in Segment 8 infiltrated the right hepatic vein (RHV), and two additional metastases were located in the left lateral segments. We used Fortner's technique to resect these tumors.

RESULTS

The postoperative course of the patient was prolonged due to a hematoma that partially compressed the new RHV graft. A re-laparotomy was performed and drains were placed. On the 15th postoperative day, the patient was discharged in good health.

CONCLUSIONS

Although nowadays patients with these unfortunate tumor locations can, to some extent, be managed non-operatively, surgery remains an option with a chance of cure. Azoulay et al. (Ann Surg 262(1):93-104, 2015) were able to show satisfactory 5-year-survival in 77 patients (30.4%), however 90-day mortality was high (19.5%). Therefore, patients need to be selected carefully. In the era of minimally invasive liver surgery, these old techniques should not vanish from the armamentarium of liver surgeons.

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.

Ante situm liver resection with inferior vena cava replacement under hypothermic cardiopolmunary bypass for hepatoblastoma: Report of a case and review of the literature

INTRODUCTION

Hepatoblastoma with tumour thrombi extending into inferior-vena-cava and right atrium are often unresectable with an extremely poor prognosis. The surgical approach is technically challenging and might require major liver resection with vascular reconstruction and extracorporeal circulation. However, which is the best surgical technique is yet unclear.

PRESENTATION OF CASE

A 11-months-old boy was referred for a right hepatic lobe mass(90×78mm) suspicious of hepatoblastoma with tumoral thrombi extending into the inferior-vena-cava and the right atrium, bilateral lung lesions and serum alpha-fetoprotein level of 50.795IU/mL. After 8 months of chemotherapy (SIOPEL 2004-high-risk-Protocol), the lung lesions were no longer clearly visible and the hepatoblastoma size decreased to 61×64mm. Thus, ante situm liver resection was planned: after hepatic parenchymal transection, hypothermic cardiopulmonary bypass was started and en bloc resection of the extended-right hepatic lobe, the retro/suprahepatic cava and the tumoral trombi was performed with concomitant cold perfusion of the remnant liver. The inferior-vena-cava was replaced with an aortic graft from a blood-group compatible cadaveric donor. The post-operative course was uneventful and after 8 months of follow-up the child has normal liver function and an alpha-fetoprotein level and is free of disease recurrence with patent vascular graft.

CONCLUSIONS

We report for the first time a case of ante situ liver resection and inferior-vena-cava replacement associated with hypothermic cardiopulmonary bypass in a child with hepatoblastoma. Herein, we extensively review the literature for hepatoblastoma with thumoral thrombi and we describe the technical aspects of ante situm approach, which is a realistic option in otherwise unresectable hepatoblastoma.

Robotic versus open liver resections: A case-matched comparison

BACKGROUND

Most hepatic resections are currently performed using an open approach. Robotic surgery might enable the transition of these procedures to minimally invasive surgery.

METHODS

Pre-, peri- and post-operative data of all patients who underwent a liver resection from 2009/2012 to 2001/2015, were collected prospectively. All robotic resection patients were matched 1:1 to patients who underwent open surgery. Pre- and perioperative data, up to 30 days, were analyzed.

RESULTS

Sixteen robotic and open hepatic resections were identified. Fewer complication events and shorter lengths of stay (LOS, 7.9 versus 11 days, P = 0.0603) were observed for robotic resections. Length of stay in the intermediate care unit (IMC) was shorter after the robotic procedure (10 h vs 16.6 h, P = 0.0699). Operating room (OR) time was significantly longer in the robotic resection cohort (352.8 vs 239.6 min, P = 0.0215). All tumor margins were negative.

CONCLUSIONS

This preliminary comparison demonstrates the general feasibility of minor robotic liver resection in selected cases.

Liver and Vena Cava En Bloc Resection for an Invasive Leiomyosarcoma Causing Budd-Chiari Syndrome, Under Veno-Venous Bypass and Liver Hypothermic Perfusion : Liver Hypothermic Perfusion and Veno-Venous Bypass for Inferior Vena Cava Leiomyosarcoma

BACKGROUND

Leiomyosarcoma of vascular origin is a rare tumor, occurring mainly in the inferior vena cava (IVC). When involving the hepatic vein confluence, it often causes Budd-Chiari syndrome, and IVC removal with a complex hepatectomy is required (Mingoli in J Am Coll Surg 211:145-146, 2010; Griffin in J Surg Oncol 34:53-60, 1987; Heaney in Ann Surg 163:237-241, 1966; Fortner in Ann Surg 180:644-652, 1974).

METHODS

A 57-year-old male, without previous oncological history, presented with Budd-Chiari syndrome due to a leiomyosarcoma extending to the supra-diaphragmatic IVC and involving the right and middle hepatic veins. The patient did not receive neoadjuvant treatment.

RESULTS

A femoral to superior vena cava veno-venous bypass was inserted, and both a median sternotomy and phreno-laparotomy with right subcostal extension were performed. A hemi-portocaval shunt was created between the right portal branch and the IVC, while a catheter was connected to the left portal branch for cold perfusion. Under extracorporeal circulation, the IVC was sectioned after infrahepatic and supra-diaphragmatic cross-clamping. The left liver was flushed with Celsior solution and packed with ice. A right trisectionectomy extended to the caudate lobe with en bloc vena cava removal was performed. The IVC was replaced by a cryopreserved aortic homograft, to which the stump of the left hepatic vein was anastomosed. Bypass duration, warm and cold liver ischemia, and operation time were 280 min, 8 min, 112 min, and 11 h, respectively. Duct-to-duct biliary anastomosis tutored by a T-tube was performed, and the patient was discharged on postoperative day 29, without major complications. After 16 months free of disease, the patient developed bilateral lung metastases. After 4 years the patient is still alive and receiving systemic chemotherapy.

CONCLUSIONS

Leiomyosarcoma of the IVC involving the hepatic veins can be treated with extended hepatectomy and removal of the IVC through extracorporeal circulation.

Extreme liver surgery as treatment of liver tumors involving the hepatocaval confluence

OBJECTIVE

Analyze the characteristics, surgical technique, morbidity and survival of patients treated with extreme liver surgery.

MATERIALS AND METHODS

We present a series of consecutive patients with malignant liver tumors in hepatocaval confluence treated in a single center with extreme liver surgery (April 2008-March 2015). Data were collected prospectively and analyzed with SPSS 21.0.

RESULTS

12 patients were included. 50 % were male and 50 % were female with a mean age of 59 ± 10 years old. The median of comorbidities was 7 according to the Charlson Age Comorbidity Index. The 75 % of the tumors were metastases, most of them from colorectal cancer. Most of the patients received neoadjuvant chemotherapy and in 58 % preoperative portal embolization was performed. Major hepatectomies were performed (66.7 % extended right hepatectomy, 33.3 % left extended hepatectomy). The 83.3 % of the patients needed vascular reconstruction. Postoperative morbidity was more than grade II in 50 % of the patients according to Dindo-Clavien classification. There was no intraoperative mortality. The postoperative mortality rate at 90 days was 33 % due to hepatic failure and biliary fistula. In December 2015, 33 % of the patients are still alive with a mean survival of 19 months (13-23) with an ECOG Performance Status of 0.

CONCLUSION

Extreme liver surgery carries a high rate of morbidity and mortality that seem to increase with age and with higher tumor volumes, according to the literature. It is a therapeutic option to consider in patients with low comorbidity suffering from malignant neoplasms that involve the hepatocaval confluence, when no other treatment with curative intention can be performed.

Protective Mechanisms of Hypothermia in Liver Surgery and Transplantation

Hepatic ischemia/reperfusion (I/R) injury is a side effect of major liver surgery that often cannot be avoided. Prolonged periods of ischemia put a metabolic strain on hepatocytes and limit the tolerable ischemia and preservation times during liver resection and transplantation, respectively. In both surgical settings, temporarily lowering the metabolic demand of the organ by reducing organ temperature effectively counteracts the negative consequences of an ischemic insult. Despite its routine use, the application of liver cooling is predicated on an incomplete understanding of the underlying protective mechanisms, which has limited a uniform and widespread implementation of liver-cooling techniques. This review therefore addresses how hypothermia-induced hypometabolism modulates hepatocyte metabolism during ischemia and thereby reduces hepatic I/R injury. The mechanisms underlying hypothermia-mediated reduction in energy expenditure during ischemia and the attenuation of mitochondrial production of reactive oxygen species during early reperfusion are described. It is further addressed how hypothermia suppresses the sterile hepatic I/R immune response and preserves the metabolic functionality of hepatocytes. Lastly, a summary of the clinical status quo of the use of liver cooling for liver resection and transplantation is provided.

Pringle's Maneuver With a Releasable Insulok Band

BACKGROUND

Currently, there are many conventional instruments being applied to perform hepatic inflow control, the Pringle's maneuver, distal to the hepatic hilum during hepatic resections. We wondered if a commonly used Insulok band can be added.

MATERIALS AND METHODS

Insulok band is a plastic tying device molded in one piece with an excellent cam-lock mechanism. We have applied releasable Insulok band to the Pringle's maneuver in 10 partial hepatectomy cases, which are not suitable for application of Chang's needle. After opening the lesser omentum, the band was passed through the Winslow foramen to the lesser sac, and the portal triad was occluded by locking the band. During the intermittent reperfusion period, this Insulok band allowed easy and fast control of hepatic inflow with its simple releasable locking device.

RESULTS

Single inflow block was used on 6 cases while repeated block on 4 cases for partial hepatectomy. The average ischemic time was 15.2 ± 8.2 minutes with an interval of 5 minutes. There was neither procedure-related morbidity nor mortality. No patient had developed postoperative hepatic failure or prolonged liver dysfunction. The efficacy of bleeding control was excellent and the average blood loss during Pringle's maneuver was 6 ± 12.6 mL. Furthermore, locking and unlocking of the Insulok band each took only 5 seconds.

CONCLUSION

Releasable Insulok band is a simpler, faster, cheaper, and safe alternative to the conventional methods for blocking hepatic inflow in Pringle's maneuver, especially in those cases not suitable for using the Chang's needle.

Ante-situm resection: a novel approach to avoid extracorporeal circulation using a transient portacaval shunt

A video abstract of this article can be viewed at http://youtu.be/iXD7859w-bU

Vascular reconstruction combined with liver resection for malignant tumours

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.

Evaluation of stapler hepatectomy during a laparoscopic liver resection

METHODS

An international database of 1499 laparoscopic liver resections was analysed using multivariate and Kaplan-Meier analysis.

RESULTS

In total, 764 stapler hepatectomies (SH) were compared with 735 electrosurgical resections (ER). SH was employed in larger tumours (4.5 versus 3.8 cm; P < 0.003) with decreased operative times (2.6 versus 3.1 h; P < 0.001), blood loss (100 versus 200 cc; P < 0.001) and length of stay (3.0 versus 7.0 days; P < 0.001). SH incurred a trend towards higher complications (16% versus 13%; P = 0.057) including bile leaks (26/764, 3.4% versus 16/735, 2.2%: P = 0.091). To address group homogeneity, a subset analysis of lobar resections confirmed the benefits of SH. Kaplan-Meier analysis in non-cirrhotic and cirrhotic patients confirmed equivalent patient (P = 0.290 and 0.118) and disease-free survival (P = 0.120 and 0.268). Multivariate analysis confirmed the parenchymal transection technique did not increase the risk of cancer recurrence, whereas tumour size, the presence of cirrhosis and concomitant operations did.

CONCLUSIONS

A SH provides several advantages including: diminished blood loss, transfusion requirements and shorter operative times. In spite of the smaller surgical margins in the SH group, equivalent recurrence and survival rates were observed when matched for parenchyma and extent of resection.

Liver resection under hypothermic total vascular exclusion

Despite progress in the field of liver surgery, centrally located tumors that involve the inferior vena cava or the hepatic veins adjacent to the vena cava are a technical challenge. These patients usually need to be operated upon under total vascular exclusion to prevent massive blood loss. The duration of vascular exclusion often exceeds the maximum permissible warm ischemia time tolerated by the liver, particularly when vascular reconstructions are necessary as part of the resection. The role of hypothermia as an adjunct to total vascular exclusion (TVE) was first introduced in 1974 but is used infrequently. A clearer understanding of this technique might allow clinicians to consider tumors in these awkward situations for resection. Additional techniques that may extend the benefits of hypothermic TVE are ante situm and ex vivo resections with autotransplantation. This review discusses the role of hypothermic TVE in the modern management of liver tumors.

Resection of an intra-operative ruptured hepatocellular carcinoma with continuous pringle maneuver and in situ hypothermic perfusion through the inferior mesenteric vein: a case report

Intra-operative tumor rupture is a serious complication during resection of large hepatocellular carcinoma (HCC) leading to more blood loss. We report our experience in applying continuous Pringle maneuver with in situ hypothermic perfusion via inferior mesenteric vein catheterization to the portal vein of the remnant liver for resection during an extended left lobectomy of a large HCC which ruptured intraoperatively. Using this method, we successfully managed the patient without any further morbidity. This technique provides easier accessibility of in situ perfusion, decreases operative blood loss and prevents warm ischemic injury to the remnant liver during parenchymal transection. This method could be effective for the resection of large ruptured HCC.

Resection and reconstruction of the inferior vena cava for neoplasms

AIM: To evaluate the results of an aggressive surgical approach of resection and reconstruction of the inferior vena cava (IVC).

METHODS: The approach to caval resection depends on the extent and location of tumor involvement. The supra- and infra-hepatic portion of the IVC was dissected and taped. Left and right renal veins were also taped to control the bleeding. In 12 of the cases with partial tangential resection of the IVC, the flow was reduced to less than 40% so that the vein was primarily closed with a running suture. In 3 of the cases, the lumen of the vein was significantly reduced, requiring the use of a polytetrafluoroethylene (PTFE) patch. In 2 of the cases with segmental resection of the IVC, a PTFE prosthesis was used and in 1 case, the IVC was resected without reconstruction due to shunting the blood through the azygos and hemiazygos veins.

RESULTS: The mean operation time was 266 min (230-310 min) with an average intraoperative blood loss of 300 mL (200-2000 mL). The patients stayed in intensive care unit for 1.8 d (1-3 d). Mean hospital stay was 9 d (7-15 d). Twelve patients (66.7%) had no complications and 6 patients (33.3%) had the following complications: acute bleeding in 2 patients; bile leak in 2 patients; intra abdominal abscess in 1 patient; pulmonary embolism in 2 patients; and partial thrombosis of the patch in 1 patient. General complications such as pneumonia, pleural effusion and cardiac arrest were observed in the same group of patients. In all but 1 case, the complications were transient and successfully controlled. The mortality rate was 11.1% (n = 2). One patient died due to cardiac arrest and pulmonary embolism in the operation room and the second one died 2 d after surgery due to coagulopathy. With a median follow-up of 24 mo, 5 (27.8%) patients died of tumor recurrence and 11 (61.1%) are still alive, but three of them have a recurrence on computed tomography.

CONCLUSION: There are a variety of options for reconstruction after resection of the IVC that offers a higher resectable rate and better prognosis in selected cases.

Regulated hepatic reperfusion mitigates ischemia-reperfusion injury and improves survival after prolonged liver warm ischemia: a pilot study on a novel concept of organ resuscitation in a large animal model

BACKGROUND

Ischemia-reperfusion injury (IRI) can occur during hepatic surgery and transplantation. IRI causes hepatic mitochondrial and microcirculatory impairment, resulting in acute liver dysfunction and failure. We proposed a novel strategy of regulated hepatic reperfusion (RHR) to reverse the cellular metabolic deficit that incurred during organ ischemia by using a substrate-enriched, oxygen-saturated, and leukocyte-depleted perfusate delivered under regulated reperfusion pressure, temperature, and pH. We investigate the use of RHR in mitigating IRI after a prolonged period of warm ischemia.

METHODS

Using a 2-hour liver warm ischemia swine model, 2 methods of liver reperfusion were compared. The control group (n = 6) received conventional reperfusion with unmodified portal venous blood under unregulated reperfusion pressure, temperature, and pH. The experimental group (n = 6) received RHR. We analyzed the effects of RHR on post-reperfusion hemodynamic changes, liver function, and 7-day animal survival.

RESULTS

RHR resulted in 100% survival compared with 50% in the control group (p = 0.05). Post-reperfusion syndrome was not observed in the RHR group, but it occurred in 83% of the control group. RHR resulted in a lesser degree of change from baseline serum alanine aminotransferase levels, aspartate aminotransferase, and lactate dehydrogenase after reperfusion compared with the control group. Histopathologic evaluation showed minimal ischemic changes in the RHR group, whereas a considerable degree of coagulative hepatocellular necrosis was observed in the control group.

CONCLUSIONS

Regulated hepatic reperfusion mitigates IRI, facilitates liver function recovery, and improves survival after a prolonged period of hepatic warm ischemia. This novel strategy has potential applicability to clinical hepatic surgery and liver transplantation when marginal grafts are used.

Inferior vena cava resection with hepatectomy: challenging but justified

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.

Comparison of major hepatectomy performed under intermittent Pringle maneuver versus continuous Pringle maneuver coupled with in situ hypothermic perfusion

BACKGROUND

The Pringle maneuver (hepatic inflow occlusion), applied intermittently or continuously, carries the risk of inducing ischemic and reperfusion injury. The risk of damage is higher in the latter procedure. Studies have shown that continuous Pringle maneuver coupled with in situ hypothermic perfusion (CPM-HP) circumvents such adversity. However, reports comparing this technique with the intermittent Pringle maneuver (IPM) are lacking. We therefore report our experience with the use of CPM-HP and compare its outcome with that of IPM.

METHODS

We evaluated the outcome of similar sets of patients who had major hepatic resections performed under IPM and CPM-HP. Variables including short-term survival rate (>90 days), complications, operative time, transection time, intraoperative blood loss, postoperative liver functions, and postoperative hospital stay were used to compare the two groups.

RESULTS

Eighteen major hepatectomies were performed with CPM-HP and 16 with IPM. CPM-HP was safely performed in patients with chronic liver disease. Lowering the liver's temperature extends the clamping period to 140 min. Perioperative outcomes including operative time (383.9 ± 89.4 vs. 351.9 ± 70.3 min, p = 0.252), blood loss (225.6 ± 48.4 vs. 351.9 ± 70.3 ml, p = 0.057), postoperative hospital stay, morbidity rate, and the rate of liver functions following resections were comparable for the CPM-HP and IPM groups. There was no mortality. Parenchymal transection time was significantly longer in the CPM-HP group (104.1 ± 20.2 vs. 85.0 ± 15.4 min, p = 0.004)

CONCLUSION

Our findings did not show there to be a significant advantage of CPM-HP over IPM.

Milestones in the evolution of hepatic surgery

This paper describes the rapid evolution of modern liver surgery, starting in the middle of the twentieth century. Claude Couinaud studied and described the segmental anatomy of the liver, Thomas Starzl performed the first liver transplantations, and Henri Bismuth introduced the concept of anatomical resections. Hepatic surgery has developed significantly since those early days. To date, innovative techniques are applied, using cutting-edge technologies: Intraoperative ultrasound, techniques of vascular exclusion of the liver, new devices for performing homeostasis and dissection, laparoscopy for resections, and new drugs that allow the resection of previously unresectable tumors. The next stage in liver surgery will probably be the implementation of a multidisciplinary holistic approach to the liver-diseased patient that will ensure the best and most efficient treatments in the future.

In situ hypothermic liver preservation during radical liver resection with major vascular reconstruction

BACKGROUND

The in situ hypothermic liver preservation technique may allow a more aggressive approach to tumours of the caval confluence and/or all three hepatic veins, which would otherwise be deemed irresectable.

METHODS

All descriptive data regarding patient demographics, operative characteristics, perioperative complications and outcomes of nine patients in whom this technique was used were collected prospectively.

RESULTS

Seven patients underwent liver trisegmentectomy and two had primary retrohepatic venal caval resection. Total hepatic vascular occlusion with in situ hypothermic liver preservation was used for venous reconstruction in all patients. The vena cava was reconstructed with prosthetic graft in seven patients. All main hepatic veins were reconstructed in the seven liver resections. In situ hypothermic liver preservation was well tolerated as evidenced by preserved hepatic synthetic function early after operation. One patient died 66 days after surgery. There were two recurrences after a median follow-up of 14 (range 2-33) months; local recurrence was identified in one patient after 4 months and distant metastasis in another after 8 months.

CONCLUSION

The in situ hypothermic liver preservation technique appears to be a useful adjunct to radical hepatobiliary tumour excision procedures that require total hepatic vascular exclusion and major vascular reconstruction.

Surgical treatment of hepatocellular carcinoma

Local tumor control is still the most important consideration in the treatment of hepatocellular carcinoma (HCC). Surgical treatments, including liver resection and liver transplantation are, and will remain, the first-line therapeutic strategies for local control in patients with primary HCC. Although aggressive liver resection is often performed for advanced HCC in patients with a large tumor, multiple tumors, or tumors with vascular invasion, liver transplantation is the preferred option, after taking into consideration age and tumor-related factors, when there is poor liver functional reserve. Preventing deterioration in liver function is the second priority in the treatment of HCC. When performing liver resection, extensive removal of noncancerous liver parenchyma during lobectomy or hemihepatectomy, should be avoided as much as possible. Anatomic resection, which refers to systematic elimination of the main tumor with its minute metastases, preserves liver function and is highly recommended. A treatment algorithm based on published evidence is now available, which helps us decide on the most suitable therapeutic option for individual patients, depending on the tumor characteristics and liver functional reserve.

Blocking intrahepatic inflow and backflow using Chang's needle during hepatic resection: Chang's maneuver

BACKGROUND

Chang's needle is a straight, 18-gauge stainless steel needle with a hook near its top to catch the thread and can be used for various hepatic resections. Since its introduction in 1996, accumulated experience has shown that using Chang's needle is simple and safe. We recently explored a new application for the needle with an intrahepatic vascular block during hepatic resections.

METHODS

Using Chang's needle makes whole-thickness interlocking sutures of the liver possible. One or two rows of multiple sutures secure the inflow and backflow while allowing a hepatic parenchymal division with less blood loss. Under ultrasound guidance, single temporary sutures can be made in the respective branches of the Glisson sheath to block inflow, and, on the right or left hepatic vein, to block backflow as well.

RESULTS

We did 89 hepatic resections without specifically aimed inflow or backflow blocks, including 12 right lobectomies, three trisegmentectomies, 21 bisegmentectomies, and 15 segmentectomies. Twenty-seven patients had mild to severe liver cirrhosis. Specifically aimed inflow blocks for partial hepatic resections were done on the Glisson sheath (G) of segment 8 (two patients), segment 6 (one patient), and segment 3 (one patient). One patient with a G8 block had a concomitant backflow block of the right hepatic vein. Overall, there was no procedure-related mortality or hepatic failure. Ischemia and reperfusion induced liver function deterioration was minimal in the group with this kind of temporary vascular blocks.

CONCLUSION

In addition to hepatic resections, Chang's maneuver can be used for intrahepatic individual inflow or backflow blocks, or both, to minimize ischemic and reperfusion injuries.