An approach to intrapericardial inferior vena cava through the abdominal cavity, without median sternotomy, for total hepatic vascular exclusion.

In surgical resection for hepatocellular carcinoma with tumor thrombus extending into the inferior vena cava and other malignancies involving the retrohepatic inferior vena cava, the usefulness of total hepatic vascular exclusion has been reported by several authors. Total hepatic vascular exclusion usually consists of clamping at three points; at the infrahepatic inferior vena cava, at the suprahepatic inferior vena cava, and in Pringles' maneuver. Tumor thrombus extending into the inferior vena cava at the intrapericardial level below the right atrium can be resected without the use of cardio-pulmonary bypass. The inferior vena cava at the intrapericardial level has been reported to be usually approached by median sternotomy such as Chevron incision. We herein demonstrate an approach to the intrapericardial inferior vena cava through the abdominal cavity without median sternotomy.     

Hepatic autotransplantation with ex situ neoplasm extirpation and vena cava replacement

The treatment of a 64-year-old man with a retrohepatic neoplasm deemed not accessible by conventional in situ surgical techniques is presented to illustrate the potential benefit offered by techniques adapted from liver transplantation and vascular surgery. A computed tomography scan performed for uncharacteristic abdominal discomfort revealed a hepatic or retrohepatic tumor compressing the inferior vena cava. Biopsies were interpreted as probably leiomyoma or malignant schwannoma. The liver with neoplasm and retrohepatic inferior vena cava was removed en bloc and taken to the back table where the neoplasm invading the inferior vena cava wall was removed together with the inferior vena cava. The inferior vena cava was then replaced by a 22-mm polytetrafluoroethylene graft and the 3 hepatic veins were reconstructed with anastomoses to this graft. The liver was then autotransplanted by standard transplantation technique. The postoperative course was uneventful and the patient is in good health more than 2 years after surgery.     

Extracorporeal bypass using a centrifugal pump during resection of malignant liver tumors.

BACKGROUND/AIMS: Total hepatic vascular exclusion (THVE) during extracorporeal bypass is used for hepatic resection in patients with malignant liver tumors. The aim of this study was to determine the efficacy of hepatectomy during total hepatic vascular exclusion using a centrifugal pump (Bio-pump). METHODOLOGY: Fourteen patients with malignant liver tumors who underwent hepatectomy during total hepatic vascular exclusion using the Bio-pump were studied retrospectively. RESULTS: In 3 of 14 patients, insufficient hepatic vascular exclusion was achieved. Six patients underwent tumor resection during total hepatic vascular exclusion, without extracorporeal bypass. In the remaining 5 patients, flow exclusion averaging 1500 ml was achieved with the Bio-pump, and hepatectomy was performed during the procedure. In these 5 patients, the mean operative time and blood loss were 11 hours 38 minutes and 6850 +/- 2451 ml. The Bio-pump bypass time, the excluded blood flow and the mean blood pressure were 82 minutes, 1650 ml and 108/53 mmHg, respectively. The arterial ketone body ratio (AKBR) decreased from a pre-operative value of 1.85-0.32 during total hepatic vascular exclusion. CONCLUSIONS: Total hepatic vascular exclusion was useful for hepatectomy in patients with tumor invasion into the hepatic vein and inferior vena cava, or tumor thrombus in the inferior vena cava and right atrium. However, this technique did not decrease blood loss or improve outcome in patients undergoing hepatectomy.     

"Ex situ-in vivo" surgery of the liver: a new technique in liver surgery. Principles and preliminary results]

Major liver resections with complex vascular reconstruction require ischemia lasting from 2 h 30 to 5 h thus exceeding hepatic tolerance to warm ischemia. We describe a new technique of "ex situ-in vivo" liver surgery with prolonged ischemia with an intact hepatic pedicle. The surgical procedure encompasses complete mobilization of the liver and inferior vena cava, inferior mesenteric and femoral to axillary vein bypass, complete vascular exclusion of the liver, cold perfusion (U. W. solution), section of the hepatic veins allowing exteriorization of the liver ("ex situ") which remains connected by the hepatic pedicle ("in vivo"). The liver is placed on a heat exchanger at 4 degrees C. This procedure was performed in three patients: one each with hepatocellular carcinoma, huge metastasis of colorectal carcinoma and a "diffuse" hemangioma. Duration of ischemia was 225, 205, and 230 min respectively. The postoperative course was uneventful in all 3 cases and patients are alive at 15, 12, and 6 months. As it improves resecability rate of liver tumors and provides radical margins of resection, this procedure may be a beneficial alternative to liver transplantation for which poor results in cancer therapy with a high rate of recurrence are mainly due to immunosuppression.     

Intraoperative massive pulmonary tumor embolism from clear cell sarcoma in the retroperitoneum: successful treatment using cardiopulmonary bypass

Malignant neoplasms rarely extend into the inferior vena cava and up to the right side of the heart. Although massive pulmonary tumor embolism occurs relatively rarely, it can be a catastrophic problem. Intraoperative pulmonary tumor embolism and cardiac arrest occurred in a 68-year-old woman while dissecting the inferior vena cava to resect a pararenal tumor extending into the retrohepatic inferior vena cava. Abrupt arterial hypotension, tachycardia, and increased central venous pressure lead to the diagnosis of massive pulmonary tumor embolism. Emergency cardiopulmonary bypass was commenced under profound hypothermia and cardiac arrest. The tumors in the main pulmonary artery were extracted, and fragments of remnant tumor were retrieved by a vascular endoscope, a Fogarty catheter, and milking of the lung. Following embolectomy, the tumor in the retrohepatic to infrarenal inferior vena cava was removed and the primary tumor together with the infrarenal inferior vena cava was resected under hepatic vascular exclusion and partial cardiopulmonary bypass. The inferior vena cava below the renal veins was not reconstructed. The patient recovered with slight retrograde amnesia. A postoperative pulmonary perfusion scintigram showed no defect in the pulmonary circulation. She is well now 8 months after surgery. Safe prevention measures should be accomplished as a part of the perioperative management of patients with inferior vena cava tumor thrombus that may be fragile, and cardiopulmonary bypass should always be stand-by on surgery.     

Surgery for hepatocellular carcinoma with tumor thrombus extending into the right atrium: report of a successful resection without the use of cardiopulmonary bypass

Hepatocellular carcinomas, of which the tumor thrombus extends into the right atrium via the inferior vena cava, may soon cause fatal complications. Only surgery can be an effective treatment. This procedure usually needs the aid of cardiopulmonary bypass. We recently experienced a successful surgery to remove thrombus combined with hepatectomy. Reporting the detailed technique, both associated diagnosis and intraoperative management are discussed herein. We were able to perform hepatectomy of tumor thrombus in the right atrium without the use of cardiopulmonary bypass or veno-venous bypass. The tumor thrombus was removed from the right atrium into the suprahepatic inferior vena cava by reducing the liver on the tail side. And after total hepatic vascular exclusion was achieved, the intracaval tumor thrombus and the right lobe of the liver were removed en bloc. The operation took 545 minutes and the total hepatic vascular exclusion period was 32 minutes. The postoperative course was uneventful. There are some key points for this procedure. Preoperative or intraoperative US is essential in judging whether tumor thrombus can be removed from the right atrium into the inferior vena cava by reducing the liver or not. Test clamping of the inferior vena cava prior to total hepatic vascular exclusion will enable us to judge whether veno-venous bypass during total hepatic vascular exclusion is needed or not. Surgery without the use of cardiopulmonary bypass is safe and can be minimally invasive when it is performed with a reliable diagnosis and technique.     

Glutaraldehyde-fixed heterologous pericardium for vena cava grafting following hepatectomy.

BACKGROUND/AIMS: Glutaraldehyde-fixed heterologous pericardium has been widely used for grafts in cardiac surgery. We applied it for inferior vena cava (IVC) patch grafting following combined resection of the liver and the IVC. METHODOLOGY: IVC grafting using a glutaraldehyde-fixed horse pericardium following combined resection of the liver and the IVC was performed in 2 patients--one with hepatocellular carcinoma and the other with hepatic metastasis following rectal cancer. The retrohepatic vena cava defect was closed with a 10 x 5 cm patch in one patient and a 7 x 4 cm patch in the other. RESULTS: Hepatic vascular exclusion was avoided in both patients. The IVC exclusion period was 40 min for the first patient and 25 min for the second. One patient required a veno-venous bypass with an active centrifugal pump of 153 min. There was no complication and no graft infection. The microscopic extension to the IVC was evident in one patient, and fibrous adhesive was evident in the IVC wall of the other. One patient died of hepatic failure 3 years and 6 months after surgery, and the other died of hepatic recurrence 7 months after surgery. Both grafts were patent, without calcification and stricture, until the patients' death. CONCLUSIONS: Glutaraldehyde-fixed heterologous pericardium is an option for IVC grafting.     

Curative resection by superior hepatectomy for advanced hepatoblastoma facilitated by the presence of a large inferior right hepatic vein

BackgroundDespite the success of neoadjuvant chemotherapy some patients with hepatoblastoma remain unresectable due to the proximity of important vascular structures. We report an unconventional surgical resection via a superior hepatectomy in a 16-month-old infant with hepatoblastoma.Case outlineStaging CT scan revealed extensive replacement of the superior portion of the liver with complete occlusion of the three hepatic veins, and with extension into the inferior vena cava and right atrium. Following chemotherapy the tumour was confined to the superior portion of the liver with obstruction of the right, middle and left hepatic veins, but with a large patent inferior hepatic vein draining the inferior liver segments. Superior hepatectomy was performed without complication.DiscussionComplete surgical resection offers the only chance of cure for patients with hepatoblastoma. This case illustrates that careful preoperative planning facilitated aggressive surgical clearance with superior hepatectomy for curative resection of an otherwise non-resectable tumour.     

Combined Transcatheter Arterial Embolization and Expanded Liver Resection for Hepatocellular Carcinoma with Multiple Intrahepatic Metastasis

After repeated transcatheter arterial embolization, a patient with hepatocellular carcinoma with multiple intrahepatic metastases in the entire lobe was successfully treated by extended right lobectomy with resection of the retrohepatic inferior vena cava under extracorporeal venovenous bypass.     

Hepatic resection through an anterior approach employing a modified liver hanging maneuver in patients with a massive liver tumor severely oppressing the inferior vena cava

For a large hepatic neoplasm existing in the right hepatic lobe, hepatic resection using an anterior approach is required. We have reported an operative procedure for hepatic transection using absorbable polyglycolic acid tape. In patients with suspected tumor invasion of the inferior vena cava, on the other hand, considering the range of the residual tumor while sparing the inferior vena cava as much as possible, combined resection and reconstruction of the inferior vena cava is conducted only if operative curativity is expected. We conducted hepatic transection while maintaining the blood flow of the residual liver by applying the liver hanging maneuver method of Belghiti et al. and polyglycolic acid tape in patients with giant liver tumors of the right hepatic lobe compressing the hepatic inferior vena cava. Strong angled dissecting forceps were inserted into the ventral side of the inferior vena cava from the caudal side, and the tip was induced between hepatic veins. Two strips of polyglycolic acid tape were pinched with forceps and strongly ligated on the right and left sides of the cutoff line. Subsequently, hepatic transection was conducted using electrocautery spray coagulation and CUSA without blocking the inflow blood of the residual liver, and the right hepatic lobe was extirpated. This procedure has already been performed in 5 patients suspected of inferior vena cava invasion, and the inferior vena cava was able to be preserved in all the patients.     

Living-donor liver transplantation in Budd-Chiari syndrome with inferior vena cava complete thrombosis: A case report and review of the literature

BACKGROUND Budd-Chiari syndrome(BCS) is a challenging indication for liver transplantation(LT) due to a combination of massive liver,increased bleeding,retroperitoneal fibrosis and frequently presents with stenosis of the inferior vena cava(IVC).Occasionally,it may be totally thrombosed,increasing the complexity of the procedure,as it should also be resected.The challenge is even greater when performing living-donor LT as the graft does not contain the retrohepatic IVC;thus,it may be necessary to reconstruct it.CASE SUMMARY A 35-year-old male patient with liver cirrhosis due to BCS and hepatocellular carcinoma beyond the Milan criteria underwent living-donor LT with IVC reconstruction.It was necessary to remove the IVC as its retrohepatic portion was completely thrombosed,up to almost the right atrium.A right-lobe graft was retrieved from his sister,with outflow reconstruction including the right hepatic vein and the branches of segment V and VIII to the middle hepatic vein.Owing to massive subcutaneous collaterals in the abdominal wall,venovenous bypass was implemented before incising the skin.The right atrium was reached via a transdiaphragramatic approach.Hepatectomy was performed en bloc with the retrohepatic vena cava.It was reconstructed with an infra-hepatic vena cava graft obtained from a deceased donor.The patient remains well on outpatient clinic follow-up 25 mo after the procedure,under an anticoagulation protocol with warfarin.CONCLUSION Living-donor LT in BCS with IVC thrombosis is feasible using a meticulous surgical technique and tailored strategies.     

Liver resection under hypothermic total vascular exclusion

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

Ex Vivo Liver Resection Followed by Autotransplantation to a Patient With Advanced Alveolar Echinococcosis With a Replacement of the Retrohepatic Inferior Vena Cava Using Autogenous Vein Grafting: A Case Report and Literature Review

Alveolar echinococcosis (AE) of the liver is a rare disease. In advanced cases of this parasitic disease, the inferior vena cava (IVC) can be invaded; in these cases, the optimal treatment is liver transplantation and replacement of the IVC. Considering the donor shortage and the drawbacks of immunosuppressive therapy, ex vivo liver resection followed by autotransplantation may be the first choice for these patients.We report the first case of advanced AE successfully treated by an ex vivo liver resection, followed by autotransplantation with a replacement of the retrohepatic IVC using autogenous vein grafting. This graft included the following regions: the bilateral great saphenous vein, part of the retrohepatic inferior vena and the middle hepatic vein with no invasion, the inferior mesenteric vein, and part of the side wall of the infrahepatic vena cava. This patient had an uneventful postoperative recovery; currently, she has been enjoying a normal life and is 12 months postoperative with no immunosuppressive therapy or AE recurrence.In conclusion, ex vivo liver resection followed by autotransplantation with a replacement of the retrohepatic IVC using autogenous vein grafting might be a useful surgical practice for advanced AE.     

Feasibility and validity of hepatic vein reconstruction in hepatectomy for hepatocellular carcinoma

The majority of hepatocellular carcinomas are complicated by liver cirrhosis. Cirrhotic patients with a tumor located in segments 7 and 8 cannot tolerate right lobectomy. To perform curative resection without causing liver failure in such patients, resection of segments 7 and 8, together with resection of the right hepatic vein, is recommended. Nine patients underwent such resection. In four patients, the right hepatic vein was not reconstructed. One patient died of liver failure and the other two patients had postoperative liver dysfunction. Based on this experience, the right hepatic vein was reconstructed in the remaining five patients; the defect was repaired by transplanting a vein graft in three patients, and a patch graft was carried out in two. In one patient who underwent reconstruction with vein graft, veno-venous bypass was performed between the remnant hepatic vein and inferior vena cava. This procedure decompressed the remnant liver and facilitated secure anastomosis in reconstruction of the hepatic vein. There were no complications or deaths. The reconstructed veins were patent 2–3 years postoperatively. This procedure is feasible and valid, and should be widely practiced in patients with a diminished liver function reserve.     

Retrohepatic vena cava deroofing in living donor liver transplantation for caudate hepatocellular carcinoma

The removal of tumor together with the native liver in living donor liver transplantation for hepatocellular carcinoma is challenged by a very close resection margin if the tumor abuts the inferior vena cava. This is in contrast to typical deceased donor liver transplantation where the entire retrohepatic inferior vena cava is included in total hepatectomy. Here we report a case of deroofing the retrohepatic vena cava in living donor liver transplantation for caudate hepatocellular carcinoma. In order to ensure clear resection margins, the anterior portion of the inferior vena cava was included. The right liver graft was inset into a Dacron vascular graft on the back table and the composite graft was then implanted to the recipient inferior vena cava. Using this technique, we observed the no-touch technique in tumor removal, hence minimizing the chance of positive resection margin as well as the chance of shedding of tumor cells during manipulation in operation.     

Primary Budd-Chiari syndrome: its significance for the choice of surgical management of a patent right inferior hepatic vein

Budd-Chiari syndrome is still a major problem and the overall prognosis for the patients is dismal and disappointing. The case history of a patient with not only outflow obstruction of the hepatic vein but also complete obstruction of the retrohepatic inferior vena cava is presented. She had a patent right inferior hepatic vein which partially decompressed the liver via a rich network of venous collaterals. Management included an inferior vena cava to inferior vena cava shunt using a Goretex graft. The patient fared well and the postoperative course was satisfactory. The case history of this patient illustrates the importance of precise pre-operative investigations for the choice of the type of surgical management. Each patient has to be considered individually on the basis of his or her mechanical peculiarities.     

Preliminary results with "ex situ" surgery for hepatic tumors: an alternative between palliative treatment and liver transplantation?]

We report 3 cases of liver tumors which were unsuitable for conventional resection and which were removed using a technique combining hypothermic portal perfusion with an anhepatic period of more than 2 hours. The liver was mobilized after section of the infra- and supra-hepatic inferior vena cava in 2 cases. The tumor was a cholangiocarcinoma in 2 cases and colonic metastasis in 1 case. Non-tumoral liver parenchyma was normal in all cases. The inferior vena cava was involved by the tumor in 2 cases. Complete tumor resection was achieved in all cases, but required reconstruction of the hepatic veins in 1 case. Two patients in whom portal venous bypass was not used developed hemodynamic failure after liver revascularization. One of them died. In patients without underlying chronic liver disease and with unresectable tumor by conventional technique, "ex situ" resection can be a worthwhile therapeutic alternative.     

Aggressive surgical resection for hepatocellular carcinoma with tumor thrombus extending to inferior vena cava and synchronous pulmonary metastasis

We describe a 66-year-old man having hepatocellular carcinoma with tumor thrombus extending into the inferior vena cava and synchronous pulmonary metastasis. He was referred to Chiba University Hospital on May, 2000, complaining of emaciation. Radiological findings showed a huge hepatocellular carcinoma in the entire right lobe and tumor thrombus extended into the intrapericardial inferior vena cava. He also had a solitary pulmonary metastasis in the left pulmonary lobe (stage IVB). Right hemihepatomy was performed under total hepatic vascular exclusion without cardiopulmonary bypass, and tumor thrombus was completely removed. Thoracoscopic wedge resection of pulmonary metastasis was also performed. The patient had an uneventful postoperative course. Histopathological examination revealed that the tumor was moderately differentiated hepatocellular carcinoma The patient is still alive after 26 months with pulmonary recurrence, but without hepatic recurrence. To our knowledge, there has been no reported case of resection for both hepatocellular carcinoma invading the inferior vena cava and synchronous pulmonary metastasis. In conclusion, aggressive surgical resection for advanced hepatocellular carcinoma concomitant with pulmonary resection may bring about better prognosis in highly selected patients.     

Aggressive combined resection of hepatic inferior vena cava, with replacement by a ringed expanded polytetrafluoroethylene graft, in living-donor liver transplantation for hepatocellular carcinoma beyond the Milan criteria

Background/purpose

We present the cases of two patients with hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) who underwent living-donor liver transplantation (LDLT) combined with aggressive hepatic venacaval resection and replacement of the hepatic inferior vena cava (IVC) by an artificial vascular graft. The aim of the resection and replacement of the hepatic IVC was to resect completely a latent cancer adjacent to the hepatic IVC and to avoid micrometastasis via the hepatic veins during increased manipulation of the native liver with HCC.

Methods

First, the hepatic hilus was dissected and the infrahepatic IVC was encircled. After minimum mobilization of the liver, the common orifice of the middle and left hepatic veins and suprahepatic IVC was encircled. Venovenous bypass (VVB) was started to stabilize systemic hemodynamics. After cross-clamping of the infrahepatic and suprahepatic IVC, the IVC was divided at the site just below the confluence of the common orifice of the middle and left hepatic veins and its infrahepatic site. Then, all retroperitoneal attachments of the right lobe were dissected and the native liver was resected with the retrohepatic IVC. The IVC was replaced by a ringed expanded polytetrafluoroethylene (e-PTFE) graft. Infrahepatic venous recirculation ended the VVB. An extended left-lobe graft was implanted. The e-PTFE grafts were covered with the greater omentum to avoid infection.

Results

The operations were completed safely. The postoperative courses were free of complications related to the reconstruction of the hepatic IVC. One patient developed recurrence in the left adrenal gland.

Conclusion

LDLT combined with hepatic venacaval resection and replacement by an e-PTFE graft for HCC beyond the MC could be safe and feasible under VVB. Further studies are needed to confirm to what extent this procedure could prevent post-transplant recurrence in HCC beyond the MC.     

Liver resection for hepatocellular carcinoma: Indications, techniques, complications, and prognostic factors

Although the resectability of hepatocellular carcinoma (HCC) has increased due to recent advances in diagnostic methods, the long-term results are far from satisfactory. Major hepatic resection is indicated in patients with noncirrhotic or mildly cirrhotic liver. Otherwise, limited resection should be carried out. Total or lobar hepatic inflow occlusion appears to decrease blood loss during surgery, and therefore to reduce postoperative morbidity and mortality rates. Total vascular exclusion with or without hypothermia may be indicated in selected patients. Hepatic resection is not necessarily contraindicated for HCC with tumor thrombus in the major portal veins, hepatic veins, inferior vena cava, and bile ducts. There are various postoperative complications, especially in cirrhotic patients, but if hepatic failure occurs, it is usually fatal. To prevent this complication, two factors may be most important: avoiding too great a resection and preventing such trigerring factors as hemorrhagic shock, infection, and gastrointestinal bleeding. Favorable prognostic factors are young age, female sex, and low serum AFP clinically, and small tumor, presence of capsule, absence of vascular invasion and/or daughter nodule, diploid or low proliferative tumor, and negative surgical margin pathologically. Increased necroinflammatory activity of the liver irrespective of viral type and hepatitis C virus-associated liver disease are associated with tumor recurrence in the remnant liver. The significance of adjuvant chemotherapy or interferon therapy remains to be elucidated.