Ex vivo liver resection and auto-transplantation as an alternative to treat liver malignancies: Progress and challenges

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 (RHIVC) 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.

EX vivo liver resection and auto transplantation for a giant hepatocellular carcinoma: A case report

INTRODUCTION AND IMPORTANCE

The curative options for locally advanced hepatocellular carcinomas involving the vessels are very limited. Ex vivo liver resection and auto transplantation (ERAT) is a novel surgical method, which has been used in the management of such complex liver space occupying lesions, which are rendered conventionally unresectable. This technique involves a complete hepatectomy, extracorporeal hepatic resection on the backbench, and then reimplantation of the remnant hepatic parenchyma. George et al. (2019) [1] In literature, Ex vivo liver resection and auto transplantation (ERAT) has been utilized in the management of both benign and malignant liver lesions, including hepatocellular carcinoma (HCC), cholangiocarcinoma, hepatic metastases, hepatic alveolar echinococcosis, focal nodular hyperplasia and hemangioma. Zawistowski et al. (2020) [2].

CASE PRESENTATION

We report this case of a 28 years old male with a giant hepatocellular carcinoma, that deemed unresectable as it was closely abutting all three hepatic veins. After appropriate preoperative surgical planning, he underwent ex vivo liver resection and autotransplantation (ERAT). Patient had gradual uneventful recovery and he was discharged home on 12th postoperative day.

CLINICAL DISCUSSION

A radical (R0) resection is the main goal of the ex vivo liver resection and autotransplantation (ERAT) procedure, which can be used for curative intent in patients with liver lesions that are conventionally inoperable. It allows for precise extracorporeal resection, maximizes the residual liver volume and increases the likelihood of obtaining negative margins. Furthermore, the bench surgery in ice bath makes it easier to reconstruct the vasculature without the pressure of time constraints in situ, unlike conventional surgery, which can take a long time when done in a bleeding operative field. Zawistowski et al. (2020) [2].

CONCLUSION

For patients with complex liver lesions believed to be incurable with conventional surgical methods, ex vivo liver resection and autotransplantation (ERAT) provides an alternative.