Combined liver resection and reconstruction of the supra-renal vena cava: the Paul Brousse experience

BACKGROUND: Liver tumors with inferior vena cava (IVC) involvement may require combined resection of the liver and IVC. This approach, with its high surgical risks and poor long-term prognosis, was precluded until the development of neoadjuvant chemotherapy, portal vein embolization, reinforced vascular prostheses, and technical advances in liver transplantation. METHODS: We reviewed 22 cases of hepatectomy with retrohepatic IVC resection and reconstruction. The patients had a median age of 51.5 years (range, 32.8-75.3 years). Indications for resection were: liver metastases (n = 9), cholangiocarcinoma (n = 8), hepatocellular carcinoma (n = 2), other cancers (n = 3). The liver resections carried out included 18 first, 3 second, and one third hepatectomy. Segment 1 (caudate lobe) was included in the specimen in 19 cases (86%). Resection concerned 1 to 6 liver segments (median = 5.0). Vascular control was achieved by vascular exclusion of the liver preserving the caval flow (n = 1), standard vascular exclusion of the liver (n = 12), in situ cold perfusion of the liver (n = 9). Ex situ surgery was not necessary in any case. Venovenous bypass was used in 12 cases. The IVC was reconstructed with a ringed Gore-Tex tube graft (n = 10), primarily (n = 8), or by caval plasty (n = 4). A main hepatic vein was reimplanted in 6 cases: into the native IVC (n = 4) or into a Gore-Tex tube graft (n = 2). RESULTS: One patient died (4.5%) due to catheter infection, 7 days after in situ cold perfusion with replacement of the vena cava. Eight patients (36%) had no complications and 14 patients (64%) had 23 complications. In all but 1 case, the complications were transient and successfully controlled. The patients stayed in intensive care for 3.3 +/- 2.0 days and in the hospital for 17.7 +/- 7.8 days. All vascular reconstructions were patent at last follow-up. With median follow-up of 19 months, 10 patients died of tumor recurrence and eleven were alive with (n = 5) or without (n = 6) disease. Actuarial 1-, 3-, and 5-year survival rates were 81.8%, 38.3%, and 38.3%, respectively. CONCLUSIONS: IVC resection and reconstruction combined with liver resection can be safely performed in selected patients. The lack of alternative treatments and the spontaneous poor prognosis justify this approach, provided that surgery is carried out at a center specialized in both liver surgery and liver transplantation. The development of adjuvant chemotherapy regimens is required to improve the long-term results of this salvage surgery.     

Ex vivo and in situ resection of inferior vena cava with hepatectomy for colorectal metastases

OBJECTIVE: To describe the surgical techniques and early results of inferior vena cava (IVC) resection in patients with advanced liver tumors. SUMMARY BACKGROUND DATA: Involvement of the IVC by hepatic tumors, although rare, is considered inoperable by standard resection techniques. Concomitant hepatic and IVC resection is required to achieve adequate tumor clearance. METHODS: Between February 1995 and February 1999, 158 patients underwent hepatic resection for colorectal metastases in the authors' unit. Eight patients, aged 42 to 80 years (mean 62 years), with hepatic metastases from colorectal cancer underwent concomitant resection of the IVC and four to six hepatic segments. Resections were carried out under total hepatic vascular exclusion in four patients and ex vivo in four patients. Between 30 degrees and 360 degrees of the retrohepatic IVC was resected and replaced with an autogenous vein patch (n = 1), a ringed Gore-Tex tube graft (n = 2), a Dacron tube graft (n = 1), or a patch (n = 3) or was repaired by primary suturing (n = 1). RESULTS: There were two early deaths from multiple organ failure. One patient survived 30 months after ex vivo resection but died of renal cell carcinoma, and another died with recurrent disease at 9 months. The remaining four patients remained alive 5 to 12 months after surgery, with no hepatic failure or venous obstruction; tumor recurrence was present in two. Nonthrombotic occlusion of the neocava occurred in one patient and was stented successfully. CONCLUSIONS: Although concomitant hepatic and IVC resection is associated with a considerable surgical risk, this aggressive surgical approach offers hope for patients with hepatic tumors involving the IVC, who would otherwise have a dismal prognosis. This procedure can be performed under total hepatic vascular exclusion, with or without venovenous bypass, and by ex vivo bench resection.     

下腔静脉重建联合肝叶切除治疗肝癌的初步研究

目的 探讨在全肝血流控制下不采用静脉转流技术行下腔静脉重建的肝叶切除治疗侵犯下腔静脉的肝癌的临床经验和疗效。方法 自2004年8月至2005年7月，对3例胆管细胞性肝癌和2例肝细胞性肝癌合并下腔静脉直接侵犯而无癌栓患者，在全肝血流控制而无静脉转流技术下行解剖性肝叶切除联合下腔静脉重建术（局部切除修复2例、局部切除补片2例、人工血管移植1例）。结果 5例患者手术均成功。平均手术时间345（300～450）min，平均手术失血量1375（1200～1800）ml。累计平均肝门阻断时间、全肝血流阻断时间和下腔静脉阻断时间分别为19min、21．2min、56min。术后发生胸腔积液1例，胆漏1例，腹水1例，均治愈。患者平均住院时间15．5（11～19）d。随访4～15个月，1例术后9个月死于肿瘤复发，4例已存活4、8、10、15个月。结论 在全肝血流控制而无静脉转流技术下行下腔静脉重建联合解剖性肝叶切除治疗直接侵犯下腔静脉的肝癌不仅可安全施行，而且可延长患者生存时间。     

Resection of the inferior vena cava for hepatic malignancy.

Involvement of the inferior vena cava (IVC) by hepatic tumors, although uncommon, is considered to be unresectable by standard surgical techniques. Recent advances in hepatic surgery have made combined hepatic and vena caval resection possible. The purpose of this study is to describe the surgical techniques and early results of combined resection of the liver and IVC. From 1997 to 2000, 11 patients underwent resection of the IVC along with four to seven liver segments. Resections were carried out for hepatocellular carcinoma (four); colorectal metastases (four); and hepatoblastoma, gastrointestinal stromal tumor metastases, and squamous cell carcinoma in one patient each. Ex vivo procedures were performed twice, and total vascular isolation was used in the nine other cases. The IVC was reconstructed with ringed Gore-Tex tube graft (five), primarily (five), or with Gore-Tex patches (one). There were two early deaths: one from liver failure at 3 weeks and one from sepsis secondary to a perforated segment of small bowel 4 months postresection. One patient with a gastrointestinal stromal tumor died at 32 months of recurrent tumor and one patient with hepatocellular carcinoma is alive with recurrent tumor at 16 months. The remaining patients are alive and disease free with follow-up ranging from 3 to 40 months without evidence of IVC occlusion. Combined resection of the liver and IVC is a formidable undertaking with substantial surgical risk. However, this aggressive surgical approach offers a chance for cure in patients with tumors involving the IVC that would otherwise have a dismal prognosis.     

Hepatic vein reconstruction for resection of hepatic tumors

SUMMARY BACKGROUND DATA: Involvement of the hepatic veins requiring reconstruction has traditionally been considered a contraindication to resection for advanced tumors of the liver because the surgical risks are high and the long-term prognosis poor. Recent advances in liver surgery gleaned from split and live donor liver transplantation that necessitate hepatic vein reconstruction can be applied to hepatic resection in some cases. METHODS: Sixteen patients who underwent hepatic resection requiring hepatic vein reconstruction from 1996-2001 were reviewed. The mean age was 43 years (range 2-61). Nine patients were resected for hepatocellular carcinoma (HCC), five patients for colorectal metastases, and one patient each for hepatoblastoma and cholangiocarcinoma. In six patients with HCC and cirrhosis, the right hepatic vein was reconstructed to provide venous outflow to liver segments not adequately drained by a remaining major hepatic vein. Four of these six patients required the use of Gore-Tex (W. L. Gore & Associates, Inc., Newark, DE) interposition grafts. In the 10 other cases the entire venous outflow from the remnant liver was reconstructed or reimplanted into the inferior vena cava primarily (n = 8) or using segments of the portal vein from the resected side of the liver as a graft (n = 2). Ex-vivo procedures with the use of veno-venous bypass were required in two cases and in-situ cold perfusion of the liver was used in one case. RESULTS: There were two perioperative deaths (12%). One patient died of liver failure 3 weeks after right trisegmentectomy with reconstruction of the left hepatic vein and one patient died at 3 months after resection due to sepsis from a segment of small bowel that perforated into a diaphragmatic hernia. Four patients had evidence of postoperative liver failure that resolved with supportive management and one patient required temporary dialysis. All vascular reconstructions were patent at last followup. With median followup of 23 months, 3 patients have died of recurrent malignancy at 14, 18 and 30 months, while an additional patient went on to die of progressive liver failure at 22 months. Actuarial 1 and 3 year survival was 88% and 50% respectively. CONCLUSION: Hepatic vein involvement by hepatic malignancy does not necessarily preclude resection. Liver resection with reconstruction of the hepatic veins can be performed in selected cases. The increased risk associated with the procedure appears to be balanced by the possible benefits, particularly when the lack of alternative curative approaches is considered.     

Adrenocortical carcinoma extending into the inferior vena cava: presentation of a 15-patient series and review of the literature

BACKGROUND: Involvement of the inferior vena cava (IVC) is a controversial risk factor for surgical treatment of adrenocortical carcinoma (ACC). This study aims to assess the outcome of an aggressive surgical policy for ACC extending into the IVC and discuss treatment strategies based on a review of the literature. METHODS: Over a 25-year period, 15 patients were treated for ACC extending into the IVC. The upper limit of the extension was the infrahepatic IVC in 2 patients, retrohepatic IVC in 6, and suprahepatic IVC in 7, including 4 with extension into the right atrium. Seven patients presented with concurrent metastases. The operative technique was thrombectomy (n = 13), partial resection with direct closure (n = 1), and total resection with replacement of the IVC (n = 1). Venous control was achieved by caval clamping alone (n = 4), hepatic vascular exclusion (n = 5), and the use of normothermic cardiopulmonary bypass or hypothermic circulatory arrest (n = 6). RESULTS: Two patients died postoperatively. Ten patients died of metastatic complications at 4 to 31 months. Median survival time was 8 months. Three patients were still alive after 24, 25, and 45 months of follow-up, one of whom was reoperated at 17 months for a local recurrence. No evidence of recurrent intravenous involvement was found during follow-up in any patient in whom complete resection was achieved. CONCLUSIONS: Our findings suggest that surgical treatment can be effective for management of ACC with extension into the IVC. Long-term prognosis is poor owing to delay in diagnosis, frequent associated metastatic disease and lack of effective adjuvant treatment.     

Resection of the inferior vena cava for neoplasms with or without prosthetic replacement: a 14-patient series

OBJECTIVE: To review the outcome of resection of the suprarenal or infrarenal inferior vena cava (IVC) and possible indications for prosthetic replacement. SUMMARY BACKGROUND DATA: Involvement of the IVC has long been considered a limiting factor for curative surgery for advanced tumors because the surgical risks are high and the long-term prognosis is poor. Prosthetic replacement of the IVC is controversial. METHODS: The authors retrospectively reviewed a 7-year series of 14 patients who underwent en bloc resection including a circumferential segment of the IVC. The tumor was malignant in 12 patients and benign in 2. The resected segment of the IVC was located above the kidneys in eight patients and below in six. Resection was performed without extracorporeal circulation in all patients. RESULTS: In all but one patient, IVC resection was associated with multivisceral resection, including extended nephrectomy (n = 8), major hepatic resection (n = 3), digestive resection (n = 3), and infrarenal aortic replacement (n = 2). Prosthetic replacement of the IVC was performed in eight patients cases and was more common after resection of a suprarenal (6/8) than an infrarenal segment of the IVC (2/6). One patient died of multiorgan failure. Major complications occurred in 29% of patients. Symptomatic complications of prosthetic replacement occurred in one patient (acute postoperative thrombosis, successfully treated by surgical disobstruction). Graft-related infection was not observed. Marked symptoms of venous obstruction developed in three of the six patients who did not undergo venous replacement. In patients undergoing surgery for malignant disease, the estimated median survival was 37 months and the actuarial survival rate was 67% at 1 year. CONCLUSION: Multivisceral resection including a segment of IVC is justified to achieve complete extirpation in selected patients with extensive abdominal tumors. Prosthetic replacement of the IVC may be required, particularly in cases of suprarenal resection. It is a safe procedure with a low complication rate and good functional results.     

Surgical treatment for colorectal liver metastases involving the paracaval portion of the caudate lobe

BACKGROUND: Hepatic neoplasms in the paracaval portion of the caudate lobe (S1r) are usually difficult to treat surgically because such neoplasms often invade the hepatic veins and/or inferior vena cava (IVC). We reevaluated resected cases of colorectal liver metastases involving S1r to confirm the significance of aggressive surgical treatments. METHODS: Between July 1977 and December 2002, 95 consecutive patients with colorectal liver metastases underwent hepatic resection. Seven patients with liver metastases involving the S1r underwent resection. RESULTS: The surgical procedures for liver metastases comprised 3 isolated caudate lobectomies, 2 right hepatectomies, and 2 right hepatic trisectionectomies with caudate lobectomy. Combined resections included partial resection of the hepatic vein in 2 patients, wedge resection of the IVC in 3, and segmental resection of the IVC in 1. Six of the 7 patients with S1r metastasis had recurrent disease in liver and/or lung. A second hepatectomy was carried out in 4 patients and a partial lung resection in 2 patients. Four of the 7 patients survived more than 5 years, but 2 of them died of recurrent disease at 61 and 95 months after initial hepatectomy. The remaining 2 patients are alive 72 and 118 months without any sign of recurrence. The median survival time of the 7 patients was 60 months. CONCLUSION: Liver metastases involving the S1r could be resected radically with en bloc resection of the major hepatic veins and/or the inferior vena cava. An aggressive surgical approach with combined resection of the adjacent major vessels may offer a better chance of long-term survival in selected patients with caudate lobe metastasis from colorectal cancer.     

Left trisegmentectomy and combined resection of the inferior vena cava, without reconstruction, for giant cystadenocarcinoma of the liver

A 54-year-old woman with giant liver cystadenocarcinoma underwent left trisegmentectomy with combined resection of the inferior vena cava (IVC) and the right hepatic vein. As a result, only the right inferior hepatic vein was preserved as a drainage vein. Because the perivertebral plexus and the azygos vein were both well developed, neither veno-venous bypass nor IVC reconstruction was performed. The developed collateral veins acted as the venous drainage pathway to maintain a stable systemic circulation. On the seventh postoperative day, portal vein flow dramatically decreased and the patient tended to liver failure. Prostaglandin E₁ (PGE₁) was administrated via the superior mesenteric artery. The portal flow then gradually increased and liver failure was avoided. Six months after the operation, she was re-admitted due to obstructive jaundice and presented with complete stenosis of the common bile duct (CBD). The jaundice persisted and liver dysfunction progressed. The patient died seven months after the operation. The confluence of the right inferior vein and the IVC could have been deformed, causing outflow blockade. The intrinsic shunt was not good enough to act as the drainage pathway, and IVC reconstruction may have been needed.     

Continuing experience with liver resection and vena cava reconstruction using cardiopulmonary bypass and hypothermic circulatory arrest

When the suprahepatic vena cava or the hepatic vein confluence with the inferior vena cava (IVC) is obscured by tumor or a clot in the IVC extends above the liver, cross-clamping the IVC during liver or retroperitoneal resection is hazardous. This report describes a 10-year experience with ten patients who had liver (seven) or retroperitoneal (three) resections with vena cava reconstruction using cardiopulmonary bypass and hypothermic circulatory arrest. There were no perioperative deaths. Morbidity consisted of prolonged bile leak (one), pulmonary embolism (one), and stroke (one). Control of the liver was secured in six of seven patients who had a liver resection. There were three significant advantages to this technique. First, the median sternotomy provided superior exposure to the suprahepatic IVC. Second, the bypass technique avoided the risks of hemodynamic instability and prevented air embolism and sudden uncontrolled hemorrhage incurred by resection or IVC cross-clamping. Third, hypothermia provided a method of protection for residual liver function especially in the face of chronic liver disease induced by infection or chemotherapy.     

Management of Retrohepatic Inferior Vena Cava Injury during Hepatectomy for Neoplasms

The aim of this article is to discuss the management of retrohepatic inferior vena cava injury during hepatectomy for neoplasms. Step-by-step hepatic vascular exclusion, digital compression, finger pinching, and surface-to-surface suturing were used in the management of retrohepatic inferior vena cava injury during hepatic resection in 16 cases: 12 patients underwent exclusion of the hepatic artery and portal vein by portal triad clamping (PTC) only; 3 underwent PTC and exclusion of the infrahepatic inferior vena cava (IVC); and 1 underwent PTC together with exclusion of the suprahepatic and infrahepatic IVC. In all cases, bleeding stopped immediately after the management described, with no intraoperative deaths and no postoperative bleeding. The median follow-up was 42.5 months (range 19–60 months) for all patients, and the 5-year survival rate of all patients with malignant tumors was 28.57%. One died of lung metastasis 19 months after operation, one with spontaneous rupture of a hepatocellular carcinoma 19 months after operation, and eight others from recurrence or metastasis 21, 23, 24, 27, 30, 35, 50, or 54 months after operation, respectively. Two patients had a recurrence 4 years and 4 years 6 months after the initial operation, respectively. The recurrent tumors of the liver were resected. The other patients are currently alive without recurrence or metastasis. The techniques described are safe, simple, practical, time-saving, and effective for controlling massive bleeding arising from injury to the retrohepatic inferior vena cava during hepatic resection.     

Hepatic resection with reconstruction of the inferior vena cava or hepatic venous confluence for metastatic liver tumor from colorectal cancer

BACKGROUND: Resection of colorectal liver metastases infiltrating the inferior vena cava (IVC) or hepatic venous confluence (HVC) is technically feasible, but the procedure frequently involves invasive techniques, and its long-term outcome has not yet been fully described. STUDY DESIGN: From October 1994 through June 2001, 87 patients underwent first curative hepatic resections for colorectal metastases. Nine patients (the IVC/HVC group) received hepatectomy combined with IVC or HVC reconstruction. Clinicopathologic characteristics, surgical results, and patient survival were investigated and compared with those of the remaining 78 patients (the comparison group). RESULTS: Three IVCs and eight hepatic veins were successfully resected and reconstructed by primary closure (n = 3), direct anastomosis (n = 1), or by the use of autologous vein grafts (n = 7). A comparison between the two groups revealed that the primary colorectal tumor stage was similar, but the IVC/HVC group had more (median 4 versus 2, p < 0.05) and larger (median 5.0 versus 3.2 cm, p < 0.05) lesions. The IVC/HVC group required longer operating times (median 600 versus 320 minutes, p < 0.001) and suffered greater blood loss (median 1,034 versus 434 g, p < 0.01) and more extensive liver parenchyma resection (median 585 versus 155 g, p < 0.001). Patients in the IVC/HVC group had a shorter survival time (median survival time 25.8 versus 44.0 months, p < 0.01). CONCLUSIONS: Hepatic resection combined with the IVC or HVC reconstruction for colorectal liver metastases can be performed with acceptable morbidity, and possibly with no mortality. Although no definite conclusion on long-term survival can be drawn from our study, given the limited number of patients, their overall survival was unsatisfactory. Further studies are needed to clarify the contribution of combined resection and reconstruction of IVC/HVC to long-term survival, because surgical resection currently provides the only hope of cure.     

Replacement of the inferior vena cava for malignancy: an update

OBJECTIVES: Resection and replacement of the inferior vena cava (IVC) to remove malignant disease is a formidable procedure. Since our initial report with IVC replacement for malignancy, we have maintained an aggressive approach to these patients. The purpose of this review is to update our experience with regard to patient selection, operative technique, and early and late outcome. METHODS: All patients who had IVC replacement for primary (n = 2) or secondary (n = 27) vena cava tumors from April 1990 to May 1999 were reviewed. Tumor location and type, clinical presentation, the segment of IVC replaced, graft patency, performance status of the patient, and tumor recurrence and survival data were collected. Late follow-up data were available for all but one patient. The IVC was replaced in 28 patients with large diameter (> or =14 mm) externally supported ePTFE grafts and with a panel graft of superficial femoral vein in the other. Three patients had a femoral arteriovenous fistula. Graft patency was determined before hospital dismissal and in follow-up by vena cavography, computed tomography, ultrasonography, or magnetic resonance imaging. RESULTS: There were 18 women and 11 men, with a mean age of 53.1 years (range, 16-88 years). Over one half of patients had symptoms from their tumor. IVC replacement was at the suprarenal segment in 15 patients, of whom 13 had concomitant major hepatic resection, at the infrarenal segment in 10, at both caval segments in three, and at the renal vein confluence in one. There were two early deaths (6.9%). One patient died intraoperatively of coagulopathy during liver resection and suprarenal IVC replacement. The other death occurred 4 months postoperatively, from multisystem organ failure that resulted in graft infection and occlusion. Twelve patients had one or more major complications- cardiopulmonary problems in five; bleeding in five; chylous ascites or large pleural effusions in two patients each; and lower extremity edema with tibial vein thrombosis in one. The mean follow-up was 2.8 years (range, 2.7 months to 6.3 years). Two late graft occlusions occurred: one at 7.5 months, the other, from tumor recurrence, at 6.3 years. There have been no other late graft-related complications. All 11 late deaths were caused by the progression of malignant disease. Of 16 survivors, 12 have no evidence of disease and four have either regional or distant metastatic recurrence. Initial postoperative performance status was good or excellent for most survivors. CONCLUSIONS: Aggressive surgical management may offer the only chance for cure or palliation of symptoms for patients with primary or secondary IVC tumors. Our experience suggests that vena cava replacement may be performed safely with low graft-related morbidity and good patency in carefully selected patients.     

布-加综合征下腔静脉阻塞合并血栓形成的治疗

目的 探讨下腔静脉阻塞并血栓形成的布-加综合征的治疗方法.方法 回顾分析近6年间收治的75例下腔静脉阻塞并血栓形成的布一加综合征患者的临床资料.其中行根治性隔膜切除、血栓取出22例,腔-腔(房)人工血管架桥41例,放射介入+内支架放置12例.结果 73例手术成功,手术死亡2例,手术后下腔静脉压力明显下降.临床症状及体征消失或缓解.随访6个月至6年,复发4例;其中人造血管堵塞2例,再发下腔静脉狭窄2例.结论 对下腔静脉阻塞合并血栓形成的布一加综合征患者,根据阻塞节段及血栓长度选择相应手术方式,大多可以取得满意效果.     

原发性下腔静脉平滑肌肉瘤的诊治体会

目的 探讨原发性下腔静脉平滑肌肉瘤的临床特点和诊治方法.方法 回顾性分析2006年6月至2009年4月收治的7例原发性下腔静脉平滑肌肉瘤的临床资料,包括临床表现、手术方法、病理结果和预后.结果 3例完整切除肿瘤,其中2例下腔静脉管壁缺损应用人工血管进行修补;1例切除部分肿瘤,恢复肝静脉血流;3例行剖腹探查肿瘤活检,明确诊断后放弃手术.7例术后病理均为原发性下腔静脉平滑肌肉瘤,3例雌激素受体(estrogen receptor,ER)、孕激素受体(progesterone receptor,PR)呈阳性,4例呈阴性.无围手术期死亡病例,3例完整切除肿瘤者术后预防性口服华法林抗凝6个月,分别随访8、32、33个月,未发现肿瘤复发和血栓形成;1例部分切除者存活2个月,死于肝功能衰竭;3例只行肿瘤活检者均于7个月内死亡.结论 完整切除肿瘤和必要的下腔静脉重建是治疗原发性下腔静脉平滑肌肉瘤的惟一有效方法.     

下腔静脉损伤的救治经验：附12例报告

目的: 探讨下腔静脉损伤的修复方法。方法:对12例下腔静脉损伤患者临床资料进行回顾性分析。结果:闭合性损伤9例，开放性损伤3例。入院时均伴有休克。均诊断为腹腔内脏损伤，无1例诊断为下腔静脉损伤。12例均手术治疗，直视下修复5例，大网膜填塞后肝实质大块褥式缝合2例，纱布填塞5例。术后并发症7例（58.3%）：胆漏1例，隔下脓肿合并反应性右侧胸腔积液2例，创伤性肝囊肿1例，腔静脉血栓形成1例，大出血2例；死亡3例，病死率25.0%。 结论:腔静脉损伤病情凶险，处理困难，病死率高，改良的全肝血流阻断下行纱布填塞止血效果好，抢救成功率高，值得推广。     

Leiomyosarcoma of the retrohepatic portion of the inferior vena cava: clinical presentation and surgical management in five patients

BACKGROUND: Leiomyosarcoma (LMS) is a rare primary soft tissue sarcoma arising from the inferior vena cava (IVC). For LMS involving the retrohepatic portion of IVC there are limited published data about tumor features, surgical strategies, and IVC replacement. STUDY DESIGN: Clinical data, surgical procedures, and pathologic features of five consecutive patients referred for IVC-LMS, in 5 years, were reviewed. A complete surgical resection of the tumor was performed in each patient and IVC replacement used expanded polytetrafluoroethylene grafts. RESULTS: Abdominal pain (n = 4) and palpable flank mass (n = 3) were the most frequent signs. To assure a complete tumoral exeresis, adjacent organ resection included hepatectomy (n = 4), extended right nephrectomy (n = 3), and right adrenalectomy (n = 1). Prosthetic IVC reconstruction was performed in four patients, three times associated with arteriovenous fistula. Median postoperative stay was 18 days. No prosthetic-related complication was observed, venous insufficiency sequela did not occur. Tumoral clearance was achieved in all patients, and direct tumoral involvement of the liver was less frequent than for kidney. Three patients died at a median followup of 34 months, two are alive and disease-free at 34 and 44 months. CONCLUSIONS: LMS of the IVC is characterized by locally advanced status at the time of diagnosis. A radical tumoral resection associated with liberal use of venous prosthetic replacement may offer a chance for cure and good quality of life in palliative situations.     

Surgical treatment of tumors involving the inferior vena cava. Personal experience

AIM: Leiomyosarcoma of the inferior vena cava (IVC) is a rare tumor that frequently produces non-specific symptoms. Surgical treatment is complex. In this review of our experience, we highlight replacement modalities of the vena cava or other vessels after complete tumor resection. METHODS: During the last 20 years, we treated 12 patients (6 women and 6 men; age range, 38-72 years) with IVC leiomyosarcoma, all apparently free of distant metastases. Tumor location, graft patency, long-term survival and tumor recurrence were recorded. The tumor arose from the IVC in 8 patients; in 2 cases the intracaval mass reached the right atrium; in 4 patients the tumor arose from the femoroiliac axis. Surgical approach was by sternolaparotomy in 5 cases and by median xyphopubic access in 7. Extracorporeal circulation (ECC) was needed in 2 cases. All tumors were removed by en bloc resection. The IVC was directly sutured in 2 patients and patched in 4; no reconstruction was necessary in 2 patients; the IVC was replaced in the remaining cases. Four patients had an additional arteriovenous fistula. One patient underwent bifurcated Dacron graft replacement of the aortic carrefour involved by tumor. RESULTS: Two patients died postoperatively. One patient developed late stenosis of the polytetrafluoroethylene (PTFE) graft, which was treated by stenting. The mean follow-up period was 35 months. The 4-year survival rate was 51% and survival free of recurrence was 63%. CONCLUSION: Leiomyosarcoma of the IVC is an uncommon tumor that produces non-specific symptoms. In the absence of distant malignancy, an aggressive approach can obtain late survival free of recurrence.     

成人间活体肝移植的手术技术改进(附13例报告)

目的探讨成人间活体肝移植的手术技术改进.方法2005年3-6月,施行了13例成人间右半肝活体肝移植,其中1例接受了2个左半肝,另1例接受了1个活体右半肝,1个尸体左半肝,术中采用了改良的手术技术,包括右肝静脉的重建,肝中静脉分支的搭桥,肝动脉搭桥及胆道吻合的改进.结果全组供体无严重并发症及死亡,受体发生并发症4例,包括肝动脉栓塞,胆漏,右膈下脓肿及肺部感染各1例,1例再移植因术后肺部感染,导致多器官衰竭（MOF）死亡.13例中除右肝静脉与下腔静脉（IVC）直接吻合,5例加行右肝下静脉重建,另5例采用自体大隐静脉搭桥行肝中静脉分支与IVC重建,保证了右肝的流出道通畅.移植物与受体重量比（GRWR）为0.72%至1.24%,其中9例＜1.0%,2例＜0.8%,无小肝综合征发生.结论采用了改进的手术技术,特别是肝静脉流出道的充分重建可有效避免小肝综合征,从而使活体右半肝移植成为相当安全的手术.     

Pathology of the inferior vena cava and liver transplantation

Pathology of the inferior vena cava is not frequently encountered in the context of liver transplantation. Such a pathology was observed in 7.9% of our recipients, in the pre- intra- and post-operative period. Pre-existing anomalies of the IVC consisted the absence of the retrohepatic vena cava in 7 children with biliary atresia; technical adjustments were quite simple. During the operative period, dissection of the supra-hepatic vena cava was made very difficult in 2 patients with hepatic alveolar echinococcosis complicated by secondary biliary cirrhosis it was necessary to make a trans-diaphragmatic approach to the inferior vena cava. Post-operative inferior vena cava thrombosis occurred in four recipients, in three cases, it was caused by the inadequate size of the graft and major anastomotic discrepancy between the inferior vena cava of donor and recipient and in one case IVC thrombosis occurred in a context of allergy to heparin. Six of the 13 recipients with pathology of inferior vena cava died directly of indirectly because of these problems. Analysis of the causes of this pathology and their possible correction will perhaps allow better results in these patients who undergo liver transplantation.