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Yang X, Lu L, Zhu WW, Tao YF, Shen CH, Chen JH, Wang ZX, Qin LX. Ex vivo liver resection and auto-transplantation as an alternative for the treatment of liver malignancies: Progress and challenges. Hepatobiliary Pancreat Dis Int 2024; 23:117-122. [PMID: 38619051 DOI: 10.1016/j.hbpd.2023.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 10/13/2023] [Indexed: 04/16/2024]
Abstract
Hepatectomy is still the major curative treatment for patients with liver malignancies. However, it is still a big challenge to remove the tumors in the central posterior area, especially if their location involves the retrohepatic inferior vena cava and hepatic veins. Ex vivo liver resection and auto-transplantation (ELRA), a hybrid technique of the traditional liver resection and transplantation, has brought new hope to these patients and therefore becomes a valid alternative to liver transplantation. Due to its technical difficulty, ELRA is still concentrated in a few hepatobiliary centers that have experienced surgeons in both liver resection and liver transplantation. The efficacy and safety of this technique has already been demonstrated in the treatment of benign liver diseases, especially in the advanced alveolar echinococcosis. Recently, the application of ELRA for liver malignances has gained more attention. However, standardization of clinical practice norms and international consensus are still lacking. The prognostic impact in these oncologic patients also needs further evaluation. In this review, we summarized the principles and recent progresses on ELRA.
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Affiliation(s)
- Xin Yang
- Hepatobiliary Surgery and Liver Transplantation Centers, Department of General Surgery, Huashan Hospital & Cancer Metastasis Institute, Fudan University, Shanghai 200040, China
| | - Lu Lu
- Hepatobiliary Surgery and Liver Transplantation Centers, Department of General Surgery, Huashan Hospital & Cancer Metastasis Institute, Fudan University, Shanghai 200040, China
| | - Wen-Wei Zhu
- Hepatobiliary Surgery and Liver Transplantation Centers, Department of General Surgery, Huashan Hospital & Cancer Metastasis Institute, Fudan University, Shanghai 200040, China
| | - Yi-Feng Tao
- Hepatobiliary Surgery and Liver Transplantation Centers, Department of General Surgery, Huashan Hospital & Cancer Metastasis Institute, Fudan University, Shanghai 200040, China
| | - Cong-Huan Shen
- Hepatobiliary Surgery and Liver Transplantation Centers, Department of General Surgery, Huashan Hospital & Cancer Metastasis Institute, Fudan University, Shanghai 200040, China
| | - Jin-Hong Chen
- Hepatobiliary Surgery and Liver Transplantation Centers, Department of General Surgery, Huashan Hospital & Cancer Metastasis Institute, Fudan University, Shanghai 200040, China
| | - Zheng-Xin Wang
- Hepatobiliary Surgery and Liver Transplantation Centers, Department of General Surgery, Huashan Hospital & Cancer Metastasis Institute, Fudan University, Shanghai 200040, China
| | - Lun-Xiu Qin
- Hepatobiliary Surgery and Liver Transplantation Centers, Department of General Surgery, Huashan Hospital & Cancer Metastasis Institute, Fudan University, Shanghai 200040, China.
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Serrablo A, Giménez-Maurel T, Utrilla Fornals A, Serrablo L, Azoulay D. Current indications of ex-situ liver resection: A systematic review. Surgery 2022; 172:933-942. [PMID: 35791978 DOI: 10.1016/j.surg.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/28/2022] [Accepted: 04/07/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ex situ liver resection and autotransplantation, a surgical technique introduced for managing advanced and unresectable malignant tumors, never became a popular surgical procedure, due mainly to the high incidence of adverse events and postoperative recurrences. This study aims to assess the clinical outcomes of ex situ liver resection and autotransplantation in the currently available literature. METHODS The PubMed electronic database was used to retrieve studies that meet the inclusion criteria for the topic. RESULTS Twenty-nine studies were included. The mean (range) 90-day mortality rate was 11.6% (0%-50%) and the mean overall survival was 55.8% (12.5%-100.0%). R0 resection was achieved in 100% of cases. In the overall study sample, the maximum tumor size was found to be positively correlated with the 90-day mortality rate (P = .047) and negatively correlated with the overall survival (P = .048). The mean number of total resected segments appeared to be positively correlated with the length of hospital stay (P = .039). In the malignant tumor sample, there was a significant relationship between the maximum tumor size and postoperative liver failure, 90-day mortality rate (P = .027 and P = .034, respectively), and between the mean length of anhepatic phase and mean length of hospital stay (P = .0092). CONCLUSION The ex situ liver resection and autotransplantation appears to be a valuable option in selected patients with conventionally unresectable hepatic tumors and normal liver function. However, it was not possible to provide clear and unequivocal recommendations about this procedure. To rectify this, an international database to help surgeons in their decision-making process ought to be established.
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Affiliation(s)
- Alejandro Serrablo
- HPB Surgical Division, Miguel Servet University Hospital, Zaragoza, Spain.
| | | | | | - Leyre Serrablo
- Surgery Department, Medicine School Zaragoza University, Zaragoza, Spain
| | - Daniel Azoulay
- Surgical Department, Centre Hépato-Biliaire Paul Brousse, VIllejuif, France
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Zawistowski M, Nowaczyk J, Jakubczyk M, Domagała P. Outcomes of ex vivo liver resection and autotransplantation: A systematic review and meta-analysis. Surgery 2020; 168:631-642. [PMID: 32727659 DOI: 10.1016/j.surg.2020.05.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/11/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
| | | | - Michał Jakubczyk
- Decision Analysis and Support Unit, SGH Warsaw School of Economics, Warsaw, Poland
| | - Piotr Domagała
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
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Zhang Y, Lai ECH, Yang C, Yang H, Liu J, Zhou G, Xian D, Deng S, Lau WY. 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. Int J Surg Case Rep 2020; 69:39-43. [PMID: 32251986 PMCID: PMC7132119 DOI: 10.1016/j.ijscr.2020.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/07/2020] [Accepted: 03/13/2020] [Indexed: 02/07/2023] Open
Abstract
Advanced HAE treated with the modified technique of ex vivo liver resection and autologous liver transplantation. The in situ reconstruction of the vascular inflow/outflow of left lateral liver section maintained the PV circulation. The subsequent autologous right liver transplantation provided additional liver functional tissues, thus reduced the risk of liver failure. 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.
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Affiliation(s)
- Yu Zhang
- Organ Transplantation Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Eric C H Lai
- Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong SAR, China
| | - Chong Yang
- Organ Transplantation Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Hongji Yang
- Organ Transplantation Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Jun Liu
- Ultrasonography Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Guo Zhou
- Ultrasonography Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Di Xian
- Organ Transplantation Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Shaoping Deng
- Organ Transplantation Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China.
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong SAR, China.
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Chen G, Chen P, You T, Jiang X, Li W, Jiang C. Allogenic Tendon-Autologous Cartilage Cells Transplantation Enhances Adhesive/Growth Ability and Promotes Chondrogenesis in a Rabbit Model of Glenoid Labrum Damage. Ann Transplant 2019; 24:532-540. [PMID: 31527567 PMCID: PMC6765340 DOI: 10.12659/aot.917518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Glenoid labrum injury of the shoulder commonly occurs in athletes, especially those who perform throwing motions. This study investigated the effects of the established allogenic tendon-autologous cartilage cells reconstruction approach in a rabbit model of glenoid labrum damage. Material/Methods The allogenic tendons were isolated and extracted using the chemical extraction method. Cartilage cells were isolated from New Zealand rabbits and identified by detecting type II collagenase. The allogenic tendon-autologous cartilage cells were transplanted to the damaged glenoid labrum. HE staining was used to observe inflammatory cells, Masson staining was used to observe muscle fibers, and scanning electron microscopy (SEM) was used to assess antigenicity of tendon tissues. PSA and AB staining were used to examine neutral protein mucopolysaccharide and acidic protein mucopolysaccharide, respectively. We assessed cartilage cell growth in autologous cartilage cells combined with allogenic tendon transplanted tissues. Results Allogenic tendons were well prepared using chemical extraction method due to use of HE staining, Masson staining, and SEM. TGF-β1 treatment induced cartilage cell formation and triggered expression of acidic and neutral protein mucopolysaccharides. HE staining, Masson staining, PAS staining, and AB staining methods showed that autologous cartilage cells combined with allogenic tendon transplanted tissues had better growth of cartilage cells. Conclusions This study establishes the allogenic tendon-autologous cartilage cells reconstruction and transplantation approach and illustrated higher adhesive ability and growth ability, and better chondrogenesis in a rabbit model of glenoid labrum damage.
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Affiliation(s)
- Guofei Chen
- Department of Traumatic Arthrosis Orthopaedics, University of Chinese Academy of Sciences-Shenzhen Hospital Shenzhen, Shenzhen, Guangdong, China (mainland)
| | - Peng Chen
- Department of Sports Medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
| | - Tian You
- Department of Sports Medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
| | - Xiaocheng Jiang
- Department of Sports Medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
| | - Wei Li
- Department of Sports Medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
| | - Changqing Jiang
- Department of Sports Medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
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Surgical approaches for definitive treatment of hepatic alveolar echinococcosis: results of a survey in 178 patients. Parasitology 2019; 146:1414-1420. [DOI: 10.1017/s0031182019000891] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AbstractHepatic alveolar echinococcosis (HAE) is a potentially fatal disease caused by the larval growth of Echinococcus multilocularis. We analysed the clinical data of 178 consecutive HAE patients treated with definitive radical surgery at our institution. According to the surgical approach: group A patients underwent direct radical hepatic resection; group B patients first underwent percutaneous puncture external drainage, followed by radical hepatic resection 2 months later; group C patients underwent a two-step hepatic resection; and group D patients underwent liver transplantation. The baseline characteristics, mortality, postoperative complications and recurrence rates were evaluated. Symptoms were present in 79.8% (142/178) patients. Bi-lobar lesion was found in 34 (19.1%, 34/178) patients, 47.2% (84/178) of whom had ⩾2 lesions each. There were no intraoperative deaths. The postoperative mortality was 2.29% in group A, 8.62% in group D and 0% in groups B and C. The main cause of death was a serious postoperative complication (Clavien–Dindo grades III–V). Patients were followed-up systematically for a median of 35.8 months (8–72) without recurrence. Active HAE should be treated by radical liver resection, and the complicated alveolar echinococcosis of the liver has been managed whenever possible using principles of radical liver resection by experienced hepatic surgeons.
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