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Azoulay D, Desterke C, Bhangui P, Serrablo A, De Martin E, Cauchy F, Salloum C, Allard MA, Golse N, Vibert E, Sa Cunha A, Cherqui D, Adam R, Saliba F, Ichai P, Feray C, Scatton O, Lim C. Rescue Liver Transplantation for Posthepatectomy Liver Failure: A Systematic Review and Survey of an International Experience. Transplantation 2024; 108:947-957. [PMID: 37749790 DOI: 10.1097/tp.0000000000004813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Rescue liver transplantation (LT) is the only life-saving option for posthepatectomy liver failure (PHLF) whenever it is deemed as irreversible and likely to be fatal. The goals were to perform a qualitative systematic review of rescue LT for PHLF and a survey among various international LT experts. METHODS A literature search was performed from 2000 to 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Population, Intervention, Comparison, Outcome framework, and to this, the authors' experience was added. The international online open survey included 6 cases of PHLF extracted from the literature and submitted to 976 LT experts. The primary outcome was whether experts would consider rescue LT for each case. Interrater agreement among experts was calculated using the free-marginal multirater kappa methodology. RESULTS The review included 40 patients. Post-LT mortality occurred in 8 (20%) cases (7/28 with proven cancer and 1/12 with benign disease). In the long term, 6 of 21 (28.6%) survivors with cancer died of recurrence (median = 38 mo) and 15 (71.4%) were alive with no recurrence (median = 111 mo). All 11 survivors with benign disease were alive and well (median = 39 mo). In the international survey among experts in LT, the percentage agreement to consider rescue LT was 28%-98%, higher for benign than for malignant disease ( P = 0.011). Interrater agreement for the primary endpoint was low, expected 5-y survival >50% being the strongest independent predictor to consider LT. CONCLUSIONS Rescue LT for PHLF may achieve good results in selected patients. Considerable inconsistencies of decision-making exist among LT experts when considering LT for PHLF.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Christophe Desterke
- University of Medicine Paris Saclay, Le Kremlin-Bicêtre, France
- INSERM Unit UMR1310, Villejuif, France
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Eleonora De Martin
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - François Cauchy
- Department of Hepato-biliary and Pancreatic Surgery and Liver Transplantation, University of Geneva, Geneva, Switzerland
| | - Chady Salloum
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Marc Antoine Allard
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Nicolas Golse
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Eric Vibert
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Antonio Sa Cunha
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - René Adam
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Faouzi Saliba
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Philippe Ichai
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Cyrille Feray
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Olivier Scatton
- Département de Chirurgie et Transplantation Hépatique, Hôpital Universitaire Pitié-Salpêtrière, Sorbonne Université, Paris, France
- Centre de Recherche de Saint-Antoine (CRSA), INSERM, UMRS-938, Paris, France
| | - Chetana Lim
- Département de Chirurgie et Transplantation Hépatique, Hôpital Universitaire Pitié-Salpêtrière, Sorbonne Université, Paris, France
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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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Lv T, Xu G, Xu X, Wu G, Wan CF, Song JL, Yang J, Zhou YJ, Luo K, Wu H, Ye CJ, Yan LN, Lau WY, Yang JY. A novel remnant liver-first strategy for liver autotransplantation in patients with end-stage hepatic alveolar echinococcosis: a retrospective case series. Int J Surg 2023; 109:3262-3272. [PMID: 37994730 PMCID: PMC10651293 DOI: 10.1097/js9.0000000000000604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/02/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Ex vivo liver resection combined with autotransplantation is an effective therapeutic strategy for unresectable end-stage hepatic alveolar echinococcosis (HAE). However, ex vivo liver resection combined with autotransplantation is a technically demanding and time-consuming procedure associated with significant morbidity and mortality. The authors aimed to present our novel remnant liver-first strategy of in vivo liver resection combined with autotransplantation (IRAT) technique for treating patients with end-stage HAE. METHODS This retrospective study included patients who underwent IRAT between January 2014 and December 2020 at two institutions. Patients with end-stage HAE were carefully assessed for IRAT by a multidisciplinary team. The safety, feasibility, and outcomes of this novel technique were analyzed. RESULTS IRAT was successfully performed in six patients, with no perioperative deaths. The median operative time was 537.5 min (range, 501.3-580.0), the median anhepatic time was 59.0 min (range, 54.0-65.5), and the median cold ischemia time was 165.0 min (range, 153.8-201.5). The median intraoperative blood loss was 700.0 ml (range, 475.0-950.0). In-hospital complications occurred in two patients. No Clavien-Dindo grade III or higher complications were observed. At a median follow-up of 18.6 months (range, 15.4-76.0) , all patients were alive. No recurrence of HAE was observed. CONCLUSION The remnant liver-first strategy of IRAT is feasible and safe for selected patients with end-stage HAE. The widespread adoption of this novel technique requires further studies to standardize the operative procedure and identify patients who are most likely to benefit from it.
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Affiliation(s)
- Tao Lv
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Gang Xu
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Xi Xu
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Gang Wu
- Department of Hepatobiliary Surgery, Qinghai Provincial People’s Hospital, Xining
| | - Chen-Fei Wan
- Department of Hepatobiliary Surgery, Qinghai Provincial People’s Hospital, Xining
| | - Jiu-Lin Song
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Jian Yang
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Yong-Jie Zhou
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Kui Luo
- Department of Radiology, Huaxi MR Research Center (HMRRC), National Clinical Research Center for Geriatrics, Frontiers Science Center for Disease-Related Molecular Network, State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu
| | - Hong Wu
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Cheng-Jie Ye
- Department of Hepatobiliary Surgery, Qinghai Provincial People’s Hospital, Xining
| | - Lv-Nan Yan
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Wan-Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, People’s Republic of China
| | - Jia-Yin Yang
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
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From liver surgery to liver transplant surgery: new developments in autotransplantation. Curr Opin Organ Transplant 2022; 27:337-345. [PMID: 36354260 DOI: 10.1097/mot.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE OF REVIEW In spite of substantial technical improvements and conceptual revolutions in advanced liver surgery, there are still straitened circumstances that pose difficulties for in-situ liver resections. Ex-vivo liver resection and autotransplantation (ELRA) is a hybrid technique combining experiences from conventional liver surgery and liver transplantation. This technique is becoming more comprehensive and popular among leading centers recently. RECENT FINDINGS Short-term and long-term outcomes are now the focus of the technique after more than a decade of cumulative progress and technical evolution. As the 5-year survival nowadays reaches over 80%, this technique is believed to be beneficial for advanced tumors. In recent years, ELRA has been applied by more centers on larger scales, and the learning curve was set at 53 cases. Progresses in disease selection, surgical indications, individualized outflow reconstruction, or autograft implantation, management of co-morbidities (e.g., Budd-Chiari syndrome, caval and/or neighboring organ involvements, obstructive jaundice) propelled the development of the technique. SUMMARY This hybrid liver surgery will benefit for carefully selected patients presented with advanced benign diseases and well-differentiated malignancies.
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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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Alikhanov R, Dudareva A, Trigo MÁ, Serrablo A. Vascular Resection for Intrahepatic Cholangiocarcinoma: Current Considerations. J Clin Med 2021; 10:jcm10173829. [PMID: 34501276 PMCID: PMC8432051 DOI: 10.3390/jcm10173829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Intrahepatic cholangiocarcinoma (iCCA) accounts for approximately 10% of all primary liver cancers. Surgery is the only potentially curative treatment, even in cases of macrovascular invasion. Since resection offers the only curative chance, even extended liver resection combined with complex vascular or biliary reconstruction of the surrounding organs seems justified to achieve complete tumour removal. In selected cases, the major vascular resection is the only change to try getting the cure. The best results are achieved by the referral centre with a wide experience in complex liver surgery, such as ALPPS procedure, IVC resection, and ante-situ and ex-situ resections. However, despite aggressive surgery, tumour recurrence occurs frequently and long-term oncological results are very poor. This suggests that significant progress in prognosis cannot be expected by surgery alone. Instead, multimodal treatment including neoadjuvant chemotherapy, radiotherapy, and subsequent adjuvant treatment for iCCA seem to be necessary to improve results.
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Affiliation(s)
- Ruslan Alikhanov
- Department of Liver and Pancreatic Surgery, Department of Transplantation, Moscow Clinical Scientific Centre, 111123 Moscow, Russia;
| | - Anna Dudareva
- Department of Vascular Surgery, Moscow Clinical Scientific Centre, 111123 Moscow, Russia;
| | - Miguel Ángel Trigo
- Department of Pathology, Miguel Servet University Hospital, 50009 Zaragoza, Spain;
| | - Alejandro Serrablo
- HPB Surgical Division, Miguel Servet University Hospital, 50009 Zaragoza, Spain
- Correspondence:
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Vascular Involvements in Cholangiocarcinoma: Tips and Tricks. Cancers (Basel) 2021; 13:cancers13153735. [PMID: 34359635 PMCID: PMC8345051 DOI: 10.3390/cancers13153735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 01/04/2023] Open
Abstract
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.
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The technical aspects of ex vivo hepatectomy with autotransplantation: a systematic review and meta-analysis. Langenbecks Arch Surg 2021; 406:2177-2200. [PMID: 33591451 DOI: 10.1007/s00423-021-02093-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/15/2021] [Indexed: 01/05/2023]
Abstract
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.
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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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Baimas-George M, Tschuor C, Watson M, Sulzer J, Salibi P, Iannitti D, Martinie JB, Baker E, Clavien PA, Vrochides D. Current trends in vena cava reconstructive techniques with major liver resection: a systematic review. Langenbecks Arch Surg 2020; 406:25-38. [PMID: 32979105 DOI: 10.1007/s00423-020-01989-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/07/2020] [Indexed: 11/11/2022]
Abstract
PURPOSE Historically, invasion of the inferior vena cava (IVC) represented advanced and often unresectable hepatic disease. With surgical and anesthetic innovations, IVC resection and reconstruction have become feasible in selected patients. This review assesses technical variations in reconstructive techniques and post-operative management. METHODS A comprehensive literature search was performed according to PRISMA. Inclusion criteria were (i) peer-reviewed articles in English; (ii) at least three cases; (iii) hepatic IVC resection and reconstruction (January 2015-March 2020). Primary outcomes were reconstructive technique, anti-thrombotic regimen, post-operative IVC patency, and infection. Secondary outcomes included post-operative complications and malignant disease survival. RESULTS Fourteen articles were included allowing for investigation of 351 individual patients. Analysis demonstrated significant heterogeneity in surgical reconstructive technique, anti-thrombotic management, and post-operative monitoring of patency. There was increased utilization of ex vivo approaches and decreased use of venovenous bypass compared with previously published reviews. CONCLUSION This review of literature published between 2015 and 2020 reveals persistent heterogeneity of hepatic IVC reconstructive techniques and peri-operative management. Increased utilization of ex vivo approaches and decreased use of venovenous bypass point towards improved operative techniques, peri-operative management, and anesthesia. In order to gain evidence for consensus on management, a registry would be beneficial.
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Affiliation(s)
- Maria Baimas-George
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - Christoph Tschuor
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA.,Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Michael Watson
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - Jesse Sulzer
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - Patrick Salibi
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - David Iannitti
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - John B Martinie
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - Erin Baker
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - Pierre-Alain Clavien
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Dionisios Vrochides
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA.
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Apaer S, Tuxun T, Li T, Aji T, Payiziwula J, Zhao JM, Shao YM, Wen H. Compared efficacy of University of Wisconsin and histidine-tryptophan-ketoglutarate solutions in ex-situ liver resection and autotransplantation for end-stage hepatic alveolar echinococcosis patients. Hepatobiliary Pancreat Dis Int 2019; 18:430-438. [PMID: 31331754 DOI: 10.1016/j.hbpd.2019.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 07/02/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND The University of Wisconsin (UW) and histidine-tryptophan-ketoglutarate (HTK) solutions are the two most frequently used liver graft preservation fluids. The present study aimed to compare their efficacy in end-stage hepatic alveolar echinococcosis patients who underwent ex-situ liver resection and autotransplantation (ELRA). METHODS A total of 81 patients received ELRA from August 2010 to March 2018. They were allocated into UW (n = 48) and HTK groups (n = 33) based on the type of solutions used. Demographic and operational data were retrospectively analyzed. Primary outcomes included 90-day mortality, incidence of early graft loss, primary dysfunction, and postoperative complications. RESULTS Demographic and operational characteristics were similarly distributed in the two groups. No statistically significant differences were observed with regard to 90-day mortality (12.77% vs. 12.12%) and early graft loss rate (8.51% vs. 9.09%) between the two groups. Patients in the UW and HTK groups showed a primary dysfunction rate of 27.66% and 27.27%, respectively. The UW group exhibited a higher incidence tendency of biliary complications, albeit with no statistical significance. CONCLUSIONS This is the largest cohort study comparing the efficacy of the UW and HTK organ-preserving solutions in end-stage hepatic alveolar echinococcosis patients in ELRA settings. UW and HTK solutions presented similar efficacy and safety. A randomized clinical trial with larger scale is needed for further investigation in future clinical applications.
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Affiliation(s)
- Shadike Apaer
- State Key Laboratory of Pathogenesis, Prevention, Treatment of High Incidence Diseases in Central Asia, Xinjiang Medical University, Urumqi 830011, China; Department of Liver Transplantation and Laparoscopic Surgery, Center of Digestive and Vascular Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Tuerhongjiang Tuxun
- State Key Laboratory of Pathogenesis, Prevention, Treatment of High Incidence Diseases in Central Asia, Xinjiang Medical University, Urumqi 830011, China; Department of Liver Transplantation and Laparoscopic Surgery, Center of Digestive and Vascular Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Tao Li
- Department of Liver Transplantation and Laparoscopic Surgery, Center of Digestive and Vascular Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Tuerganaili Aji
- Department of Hepatobiliary and Hydatid Surgery, Center of Digestive and Vascular Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Jiangduosi Payiziwula
- Department of Liver Transplantation and Laparoscopic Surgery, Center of Digestive and Vascular Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Jin-Ming Zhao
- Department of Liver Transplantation and Laparoscopic Surgery, Center of Digestive and Vascular Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Ying-Mei Shao
- Department of Hepatobiliary and Hydatid Surgery, Center of Digestive and Vascular Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Hao Wen
- State Key Laboratory of Pathogenesis, Prevention, Treatment of High Incidence Diseases in Central Asia, Xinjiang Medical University, Urumqi 830011, China; Department of Liver Transplantation and Laparoscopic Surgery, Center of Digestive and Vascular Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China; Department of Hepatobiliary and Hydatid Surgery, Center of Digestive and Vascular Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China; WHO Collaborating Center for Prevention and Care Management of Echinococcosis, the First Affiliated Hospital of Xinjiang Medical University and Xinjiang Center for Disease Control, Urumqi 830054, China.
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12
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Ozsoy M, Ozsoy Z, Yilmaz S, Arikan Y. Ex situ Liver Resection and Partial Liver Autotransplantation for Advanced Cholangiocarcinoma. Niger J Surg 2019; 25:97-100. [PMID: 31007521 PMCID: PMC6452762 DOI: 10.4103/njs.njs_4_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Surgery is the only known curative treatment option for cholangiocarcinoma. Ex situ liver surgery and autotransplantation are promising approaches in cases that cannot be treated by conventional methods and particularly in the presence of centrally localized liver tumors as well as tumors that invade the main vascular structures. A 53-year-old female patient presented with abdominal pain and nausea. Abdominal tomography showed a tumoral mass lesion that filled the left lobe of the liver and invaded the left hepatic vein and the inferior vena cava. Cholangiocarcinoma diagnosis was reached based on biopsy findings, and the patient was scheduled for surgery as positron emission tomography did not indicate any other disease focus. The patient underwent ex situ liver resection and autotransplantation. She was discharged on the 7th postoperative day. A 68-year-old male presented with abdominal pain, weakness, and weight loss. Laboratory analysis indicated elevated carbohydrate antigen 19-9: 400 U/ml and alpha-fetoprotein (AFP): 2000 U/ml, and there was no other pathology. Abdominal tomography showed a mass that filled the center of the liver and invaded the left hepatic vein and the inferior vena cava. Pathological findings of the biopsy sample were reported as combined hepatocellular-cholangiocellular carcinoma. The patient's AFP levels continued to increase despite transcatheter arterial chemoembolization and radiofrequency ablation therapy. Surgery was decided as indocyanine green clearance test, and the result was 8.5%. He underwent ex situ liver resection and autotransplantation. Unfortunately, he died on the 4th postoperative day due to respiratory failure. Ex vivo liver resection and partial liver autotransplantation should be considered for the surgical treatment of locally advanced cholangiocarcinomas that invaded the main vascular structures.
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Affiliation(s)
- Mustafa Ozsoy
- Department of General Surgery, Parkhayat Hospital, Afyon, Turkey
| | - Zehra Ozsoy
- Department of Internal Medicine, State Hospital, Afyon, Turkey
| | - Sezgin Yilmaz
- Department of General Surgery, Faculty of Medicine, Afyon Kocatepe University, Afyon, Turkey
| | - Yüksel Arikan
- Department of General Surgery, Faculty of Medicine, Afyon Kocatepe University, Afyon, Turkey
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13
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Vascular infiltration-based surgical planning in treating end-stage hepatic alveolar echinococcosis with ex vivo liver resection and autotransplantation. Surgery 2018; 165:889-896. [PMID: 30591376 DOI: 10.1016/j.surg.2018.11.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/30/2018] [Accepted: 11/16/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND For end-stage hepatic alveolar echinococcosis, insufficient guidance is available regarding surgical treatment, especially for ex vivo liver resection combined with autotransplantation. The indications for this complex surgery require further discussion. METHOD We reviewed 50 cases of patients who underwent ex vivo liver resection combined with autotransplantation from January 2014 to February 2018. A newly developed classification was used to describe vascular infiltration in all patients, who were divided into four groups based on anatomic lesion features and surgical patterns. The surgical planning for ex vivo liver resection combined with autotransplantation is then thoroughly discussed according to the gathered information. RESULTS In all patients, the length of the operation and the anhepatic phase were 735 minutes (range, 540-1,170 minutes) and 309 minutes (range, 122-480 minutes), respectively. The median remnant liver volume-to-standard liver volume ratio was 0.58 (range, 0.32-1.11). The rate of complications classified as Clavien-Dindo grade III or higher was 22% (11/50). A total of 3 postoperative deaths occurred. We identified 4 types with distinguished lesion anatomic features. Type I patients required more frequent unconventional reconstruction of the portal vein and bile duct than the other patients. Of the 6 type IV patients, 4 required modification of the surgical protocol according to intraoperative findings. CONCLUSION Vascular infiltration-based classification could improve the anatomic comprehension and, thus, facilitate surgical planning for ex vivo liver resection combined with autotransplantation. Through cautious evaluation of operability, liver function, and residual liver volume, together with delicate operative techniques and careful postoperative management, ex vivo liver resection combined with autotransplantation can achieve good results in the treatment of end-stage hepatic alveolar echinococcosis.
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Sun Z, Ding Y, Jiang Y, Zhang Q, Li Z, Xiang J, Duan J, Yan S, Wang W. Ex situ hepatectomy and liver autotransplantation for a treating giant solitary fibrous tumor: A case report. Oncol Lett 2018; 17:1042-1052. [PMID: 30655864 PMCID: PMC6312964 DOI: 10.3892/ol.2018.9693] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 09/17/2018] [Indexed: 12/13/2022] Open
Abstract
A solitary fibrous tumor (SFT) is a rare mesenchymal tumor. Ex situ hepatectomy and liver autotransplantation are novel methods for the treatment of complicated liver tumors, for example, those involving vascular structures, including the inferior vena cava, which are unresectable by conventional approaches. The present study describes a rare case of a massive hepatic SFT in a 32-year-old female who underwent ex situ hepatectomy and liver autotransplantation to achieve a radical resection. The surgery was without complications. Post-operative histopathological and immunohistochemical examinations revealed an SFT of the liver. The patient was discharged 29 days after the surgery with fully recovered liver function. The routine check-up 3 months after surgery indicated normal liver function and no evidence of recurrence. Additionally, an exhaustive review of available literature was performed to provide a complete overview of the current status of SFTs. In summary, the present study found that ex situ hepatectomy and liver autotransplantation are suitable surgical techniques for treating a giant SFT, as well as other liver neoplasms that are considered unresectable by conventional surgery.
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Affiliation(s)
- Zhongquan Sun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310003, P.R. China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang 310003, P.R. China
| | - Yuan Ding
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310003, P.R. China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang 310003, P.R. China
| | - Yuancong Jiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310003, P.R. China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang 310003, P.R. China
| | - Qiyi Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310003, P.R. China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang 310003, P.R. China
| | - Zhiwei Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310003, P.R. China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang 310003, P.R. China
| | - Jie Xiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310003, P.R. China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang 310003, P.R. China
| | - Jixuan Duan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310003, P.R. China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang 310003, P.R. China
| | - Sheng Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310003, P.R. China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang 310003, P.R. China
| | - Weilin Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China.,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou, Zhejiang 310003, P.R. China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, Zhejiang 310003, P.R. China
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15
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Ex vivo liver resection and autotransplantation as alternative to allotransplantation for end-stage hepatic alveolar echinococcosis. J Hepatol 2018; 69:1037-1046. [PMID: 30031886 DOI: 10.1016/j.jhep.2018.07.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/02/2018] [Accepted: 07/09/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Radical resection is the best treatment for patients with advanced hepatic alveolar echinococcosis (AE). Liver transplantation is considered for selected advanced cases; however, a shortage of organ donors and the risk of postoperative recurrence are major challenges. The aim of this study was to assess the clinical outcomes of ex vivo liver resection and autotransplantation for end-stage AE. METHODS In this prospective study, 69 consecutive patients with end-stage hepatic AE were treated with ex vivo resection and liver autotransplantation between January 2010 and February 2017. The feasibility, safety and long-term clinical outcome of this technique were assessed. RESULTS Ex vivo extended hepatectomy with autotransplantation was successful in all patients without intraoperative mortality. The median weight of the graft and AE lesion were 850 (370-1,600) g and 1,650 (375-5,000) g, respectively. The median duration of the operation and anhepatic phase were 15.9 (8-24) h and 360 (104-879) min, respectively. Six patients did not need any blood transfusion. Complications higher than IIIa according to Clavien classification were observed in 10 patients. The 30-day-mortality and overall mortality (>90 days) were 7.24% (5/69) and 11.5% (8/69), respectively. The mean hospital stay was 34.5 (12-128) days. Patients were followed-up systematically for a median of 22.5 months (14-89) without recurrence. CONCLUSION This is the largest series assessing ex vivo liver resection and autotransplantation in end-stage hepatic AE. This technique could be an effective alternative to liver transplantation in patients with end-stage hepatic AE, with the advantage that it does not require an organ nor immunosuppressive agents. LAY SUMMARY Ex vivo liver resection and autotransplantation were performed in a large series of patients with end-stage hepatic alveolar echinococcosis. The results showed that this surgical option was feasible, with acceptable postoperative mortality, but 100% disease-free survival in survivors. Careful patient selection, as well as precise assessment for size and quality of the remnant liver are key to successful surgery.
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16
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Vicente E, Quijano Y, Ielpo B, Duran H, Diaz E, Fabra I, Malavé L, Ferri V, Lazzaro S, Kalivaci D, Caruso R. Ex Situ Hepatectomy and Liver Autotransplantation for Cholangiocarcinoma. Ann Surg Oncol 2017; 24:3990-3990. [DOI: 10.1245/s10434-017-6104-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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17
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Yamamoto M, Akamatsu N, Hayashi A, Togashi J, Sakamoto Y, Tamura S, Hasegawa K, Fukayama M, Makuuchi M, Kokudo N. Safety and efficacy of venous reconstruction in liver resection using cryopreserved homologous veins. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:511-519. [PMID: 28660678 DOI: 10.1002/jhbp.488] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Only a few studies have reported the resection and reconstruction of major hepatic veins during hepatectomy. Here, we present our strategy and techniques for venous reconstruction with cryopreserved homologous veins, and describe the surgical outcome. METHODS Among 2,387 hepatectomy patients, 39 patients who required hepatic venous reconstruction were reviewed retrospectively. Venous reconstruction was performed to secure a non-congested liver remnant volume of at least 40% of the total liver volume. RESULTS There was no operative mortality, and the severe morbidity rate was 5% in this series. A total of 41 veins were reconstructed; 30 with homologous veins (73.2%) and 11 with autologous veins (26.8%), with the middle hepatic vein being the most frequent (n = 23, 56%). Interposition grafting was performed more often (P = 0.003), the length of the venous resection was longer (P = 0.007), and pathologic wall infiltration of the vein was revealed more often (P = 0.002) in the homologous graft group than in the autologous graft group. The 1-, 2-, and 3-year overall patency of the reconstructed veins was 55.4%, 46.3%, and 46.3%, respectively. CONCLUSIONS Aggressive venous reconstruction during hepatectomy using cryopreserved homologous veins is a feasible option with satisfactory short-term outcomes, and may be warranted to improve operative safety.
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Affiliation(s)
- Masaki Yamamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Akimasa Hayashi
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Togashi
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Sumihito Tamura
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Masashi Fukayama
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Masatoshi Makuuchi
- Division of Hepato-Billiary-Pancreatic Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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18
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Li W, Han J, Wu ZP, Wu H. Surgical management of liver diseases invading the hepatocaval confluence based on IH classification: The surgical guideline in our center. World J Gastroenterol 2017; 23:3702-3712. [PMID: 28611523 PMCID: PMC5449427 DOI: 10.3748/wjg.v23.i20.3702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/15/2017] [Accepted: 04/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM to investigate the short-term outcomes and risk factors indicating postoperative death of patients with lesions adjacent to the hepatocaval confluence.
METHODS We retrospectively analyzed 54 consecutive patients who underwent hepatectomy combined with inferior vena cava (IVC) and/or hepatic vein reconstruction (HVR) from January 2012 to January 2016 at our liver surgery center. The patients were divided into 5 groups according to the range of IVC and hepatic vein involvement. The patient details, indications for surgery, operative techniques, intra- and postoperative outcomes were compared among the 5 groups. Univariate and multivariate analyses were performed to explore factors predictive of overall operative death.
RESULTS IVC replacement was carried out in 37 (68.5%) patients and HVR in 17 (31.5%) patients. Type I2H2 had the longest operative blood loss, operative duration and overall liver ischemic time (all, P < 0.05). Three patients of Type I3H1 with totally occluded IVC did not need IVC reconstruction. Total postoperative morbidity rate was 40.7% (22 patients) and the operative mortality rate was 16.7% (9 patients). Factors predictive of operative death included IVC replacement (P = 0.048), duration of liver ischemia (P = 0.005) and preoperative liver function being Child-Pugh B (P = 0.025).
CONCLUSION IVC replacement, duration of liver ischemia and preoperative poor liver function were risk factors predictive of postoperative death. We should be cautious about IVC replacement, especially in Type I2H2. For Type I3H1, it was unnecessary to replace IVC when the collateral circulation was established.
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19
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Ye QF, Senninger N. The consensus on liver autotransplantation from an international panel of experts. Hepatobiliary Pancreat Dis Int 2017; 16:10-16. [PMID: 28119253 DOI: 10.1016/s1499-3872(16)60175-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Qi-Fa Ye
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430071, China; Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, The 3rd Xiangya Hospital of Central South University, Changsha 410013, China.
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20
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Abstract
With surgery for hepatic malignancy, there are poor options for chemotherapy; many patients are deemed unresectable because of vascular involvement or location of tumors. Over the past few decades, advances in surgical technique have allowed resection of these tumors with vascular reconstruction to achieve negative margins and improve chances for survival. This article reviews those reconstruction techniques and outcomes in detail, including in situ perfusion and ex vivo liver surgery, and provides a discussion of implications and operative planning for patients with hepatic malignancy in order to provide surgeons with better understanding of these complicated operations.
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Affiliation(s)
- Jennifer Berumen
- Division of Transplantation and Hepatobiliary Surgery, University of California San Diego, 9300 Campus Point Drive, #7745, La Jolla, CA 92037, USA.
| | - Alan Hemming
- Division of Transplantation and Hepatobiliary Surgery, University of California San Diego, 9300 Campus Point Drive, #7745, La Jolla, CA 92037, USA
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21
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Wen H, Dong JH, Zhang JH, Duan WD, Zhao JM, Liang YR, Shao YM, Ji XW, Tai QW, Li T, Gu H, Tuxun T, He YB, Huang JF. Ex Vivo Liver Resection and Autotransplantation for End-Stage Alveolar Echinococcosis: A Case Series. Am J Transplant 2016; 16:615-24. [PMID: 26460900 DOI: 10.1111/ajt.13465] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/12/2015] [Accepted: 07/14/2015] [Indexed: 01/25/2023]
Abstract
The role of autotransplantation in end-stage hepatic alveolar echinococcosis (AE) is unclear. We aimed to present our 15-case experience and propose selection criteria for autotransplantation. All patients were considered to have unresectable hepatic AE by conventional resection due to critical invasion to retrohepatic vena cava, hepatocaval region along with three hepatic veins, and the tertiary portal and arterial branches. All patients successfully underwent ex vivo extended right hepatectomy and autotransplantation without intraoperative mortality. The median autograft weight was 706 g (380-1000 g); operative time was 15.5 hours (11.5-20.5 hours); and anhepatic time was 283.8 minutes (180-435 min). Postoperative hospital stay was 32.3 days (12-60 days). Postoperative complication Clavien-Dindo grade IIIa or higher occurred in three patients including one death that occurred 12 days after the surgery due to acute liver failure. One patient was lost to follow-up after the sixth month. Thirteen patients were followed for a median of 21.6 months with no relapse. This is the largest reported series of patients with end-stage hepatic AE treated with liver autotransplantation. The technique requires neither organ donor nor postoperative immunosuppressant. The early postoperative mortality was low with acceptable morbidity. Preoperative precise assessment and strict patient selection are of utmost importance.
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Affiliation(s)
- H Wen
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - J-H Dong
- Department of Hepatobiliary Surgery, Beijing Tsinghua Chang Gung Hospital, Beijing, P.R. China
| | - J-H Zhang
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - W-D Duan
- Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, P.R. China
| | - J-M Zhao
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - Y-R Liang
- Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, P.R. China
| | - Y-M Shao
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - X-W Ji
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - Q-W Tai
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - T Li
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - H Gu
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - T Tuxun
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - Y-B He
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - J-F Huang
- Department of Hepatobiliary Surgery, Peking Union Medical College Hospital, Beijing, P.R. China
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He YB, Bai L, Jiang Y, Ji XW, Tai QW, Zhao JM, Zhang JH, Liu WY, Wen H. Application of a Three-Dimensional Reconstruction Technique in Liver Autotransplantation for End-Stage Hepatic Alveolar Echinococcosis. J Gastrointest Surg 2015; 19:1457-65. [PMID: 25967139 DOI: 10.1007/s11605-015-2842-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 04/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND The purpose of this study was to determine the clinical value of three-dimensional (3D) computer reconstruction technology in pre-operative assessment and surgical planning for liver autotransplantation in patients with end-stage hepatic alveolar echinococcosis (HAE). STUDY DESIGN Fifteen end-stage HAE patients received surgical treatment in our hospital between May 2011 and July 2014. 3D reconstruction and virtual surgeries were performed on diseased livers using a 3D reconstruction system for liver (IQQA-Liver). The feasibility and safety of liver autotransplantation were assessed for successful implementation of surgery. The results were compared with intraoperative conditions and computed tomography (CT) to verify the accuracy of pre-operative evaluation. RESULTS Fifteen patients underwent liver resections and liver autotransplantation using surgical strategies consistent with pre-operative surgical planning in 3D reconstruction. Furthermore, there was no significant difference between whole-liver volume (2848.26 ± 798.41 vs. 2598.70 ± 822.45 cm(3), t = -4.635, P > 0.05) and lesion volume (1159.09 ± 789.47 vs. 1213.14 ± 813.76 cm(3), t = -1.959, P > 0.05) measured by 3D and traditional two-dimensional (2D) manual tracing from CT. The remaining liver volumes calculated by 3D and 2D CT were 810.47 ± 214.05 and 892.00 ± 262.36 cm(3) (t = -3.275, P > 0.05), with an average error rate of 6.2 and 16.5%, respectively. The pre-operative remaining liver volumes estimated by the two methods were positively correlated with the actual weight (783.67 ± 217.74 g) after the surgery (r three-dimensional = 0.976, r multislice CT = 0.883, P < 0.01). CONCLUSIONS An individualized liver reconstruction technique can provide comprehensive anatomic information on livers of patients with end-stage HAE. Pre-operative virtual surgery can effectively improve the success rate of liver autotransplantation and reduce the risks of surgery.
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Affiliation(s)
- Yi-Biao He
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, 1st Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, 830054, China
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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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Wang FQ, Lu Q, Yan J, Peng YY, Xie CR, Su YJ, Zhou JY, Wang BL, Zhao WX, Wang XM, Bie P, Yin ZY. Ex vivo hepatectomy and partial liver autotransplantation for hepatoid adenocarcinoma: A case report. Oncol Lett 2015; 9:2199-2204. [PMID: 26137040 DOI: 10.3892/ol.2015.3041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 02/26/2015] [Indexed: 01/16/2023] Open
Abstract
We previously reported the case of a 56-year-old male who underwent surgical treatment for gastric hepatoid adenocarcinoma and splenic metastasis. The present study reports the case of the same patient who underwent successful ex vivo hepatectomy and partial liver autotransplantation. Computed tomography scans demonstrated that the tumor was located in the left and caudate lobes of the liver, with hepatic vein and inferior vena cava involvement, and right portal vein compression. To clarify the association between the vessels and the tumor, a three-dimensional imaging technique was used to reconstruct the liver architecture. During the surgery, the whole liver was removed with the retrohepatic vena cava, which was replaced with a prosthetic graft without a veno-venous bypass; a portacaval shunt for the anhepatic phase was performed simultaneously. The surgery lasted 9 h, and the anhepatic phase lasted 4 h. Blood loss during the surgery was recorded at 1,500 ml. The time taken for recovery was 21 days post-surgery, and at 20 months, the patient was disease-free. To the best of our knowledge, this is the first case of ex vivo liver resection performed for hepatic metastasis of hepatoid adenocarcinoma to be reported.
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Affiliation(s)
- Fu-Qiang Wang
- Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Fujian Provincial Key Laboratory of Chronic Liver Disease and Hepatocellular Carcinoma, Xiamen, Fujian, P.R. China
| | - Qian Lu
- Department of Hepatobiliary Surgery, Southwest Hospital, The Third Military Medical University, Chongqing, P.R. China
| | - Jun Yan
- Department of Hepatobiliary Surgery, Southwest Hospital, The Third Military Medical University, Chongqing, P.R. China
| | - You-Yuan Peng
- Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Fujian Provincial Key Laboratory of Chronic Liver Disease and Hepatocellular Carcinoma, Xiamen, Fujian, P.R. China
| | - Cheng-Rong Xie
- Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Fujian Provincial Key Laboratory of Chronic Liver Disease and Hepatocellular Carcinoma, Xiamen, Fujian, P.R. China
| | - Yong-Jie Su
- Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Fujian Provincial Key Laboratory of Chronic Liver Disease and Hepatocellular Carcinoma, Xiamen, Fujian, P.R. China
| | - Jian-Yin Zhou
- Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Fujian Provincial Key Laboratory of Chronic Liver Disease and Hepatocellular Carcinoma, Xiamen, Fujian, P.R. China
| | - Bo-Liang Wang
- School of Information Science and Technology, Xiamen University, Xiamen, Fujian, P.R. China
| | - Wen-Xiu Zhao
- Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Fujian Provincial Key Laboratory of Chronic Liver Disease and Hepatocellular Carcinoma, Xiamen, Fujian, P.R. China
| | - Xiao-Min Wang
- Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Fujian Provincial Key Laboratory of Chronic Liver Disease and Hepatocellular Carcinoma, Xiamen, Fujian, P.R. China
| | - Ping Bie
- Department of Hepatobiliary Surgery, Southwest Hospital, The Third Military Medical University, Chongqing, P.R. China
| | - Zhen-Yu Yin
- Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Fujian Provincial Key Laboratory of Chronic Liver Disease and Hepatocellular Carcinoma, Xiamen, Fujian, P.R. China
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Mekeel KL, Hemming AW. Evolving role of vascular resection and reconstruction in hepatic surgery for malignancy. Hepat Oncol 2013; 1:53-65. [PMID: 30190941 DOI: 10.2217/hep.13.5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Primary and secondary hepatic malignancies, including hepatocellular cancer, cholangiocarcinoma and metastatic disease from colorectal cancer continue to increase in incidence worldwide, and remain diseases with a high mortality. Liver resection, with negative margins, is associated with improved survival and better quality of life over nonoperative treatment. As liver resection continues to evolve, aggressive centers are increasingly using vascular resection and reconstruction to achieve negative margins and improve outcomes. As these resections become more common, the morbidity and mortality associated with these complex surgical procedures is decreasing. Currently, resections of the portal vein are becoming routine in major liver and pancreatic resections, and experience with hepatic artery, hepatic vein and inferior vena cava resections is increasing. This review paper looks at the current indications, techniques and outcomes for major vascular resection in hepatic malignancy.
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Affiliation(s)
- Kristin L Mekeel
- Division of Transplant & Hepatobiliary Surgery, University of California, San Diego, CA 92103, USA
| | - Alan W Hemming
- Division of Transplant & Hepatobiliary Surgery, University of California, San Diego, CA 92103, USA
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