Remnant Liver-to-Standard Liver Volume Ratio Below 40% is Safe in Ex Vivo Liver Resection and Autotransplantation

Particular Chinese contributions to extracorporeal liver surgery

Extracorporeal liver surgery (ELS), also known as liver autotransplantation, is a hybrid (cross-fertilized) surgery incorporating the technical knowledge from extreme liver and transplant liver surgeries, and recently became more embraced and popularized among leading centers. ELS could be summarized into three major categories, namely, ex-situ liver resection and autotransplantation (ELRA), ante-situm liver resection and autotransplantation (ALRA) and auxiliary partial liver autotransplantation (APLA). The successful development of ELS during the past 37 years is definitely inseparable from continuous efforts done by Chinese surgeons and researchers. Especially, the precision liver surgery paradigm has allowed to transform ELS into a modularized, more simplified, and standardized surgery, to upgrade surgical skills, to improve peri-operative outcome and long-term survival, to increase the capability of surgeons to select more complex diseases and to expand the level of medical service to the population. This review highlights the Chinese contributions to the field of ELS, focusing thereby on features of different surgical types, technical innovations, disease selection and surgical indication, patient prognosis and future perspectives.

Insight into the history and trends of liver transplantation for echinococcosis: A bibliometric analysis

BACKGROUND

Liver transplantation (LT) has demonstrated favorable efficacy in managing end-stage alveolar echinococcosis. Nevertheless, the current research focal points and advancement trends remain ambiguous.

AIM

To map the research landscape to underscore critical areas of focus, influential studies, and future directions of LT for echinococcosis treatment.

METHODS

Publications on LT for echinococcosis treatment published between 1900 and 2023 were searched in the Web of Science database and analyzed using bibliometrics.

RESULTS

A total of 14 countries/regions, 75 institutions, and 499 authors have published research articles, with China, Turkey, and France being the three most productive countries. The four institutions with the most contributions were Sichuan University, Xinjiang Medical University, the University de Franche Comte, and Inonu University. The three authors who contributed the most were Wen Hao, Wang Wentao, and Bresson Hadni Solange. The four most common keywords were alveolar echinococcosis, LT, ex-vivo liver resection and autotransplantation, and echinococcosis multilocularies.

CONCLUSION

Our study found that the treatment of complications after LT for echinococcosis treatment and the preoperative surgical plan based on the anatomical relationship between the lesion and the blood vessel are early research hotspots. Recent research focuses on the treatment of complications after ex-vivo liver resection and autotransplantation, especially vascular complications.

Liver autotransplantation and atrial reconstruction on a patient with multiorgan alveolar echinococcosis: a case report

BACKGROUND

Alveolar echinococcosis (AE) primarily affects the liver and potentially spreads to other organs. Managing recurrent AE poses significant challenges, especially when it involves critical structures and multiple major organs.

CASE PRESENTATION

We present a case of a 59-year-old female with recurrent AE affecting the liver, heart, and lungs following two previous hepatectomies, the hepatic lesions persisted, adhering to major veins, and imaging revealed additional diaphragmatic, cardiac, and pulmonary involvement. The ex vivo liver resection and autotransplantation (ELRA), first in human combined with right atrium (RA) reconstruction were performed utilizing cardiopulmonary bypass, and repairs of the pericardium and diaphragm. This approach aimed to offer a potentially curative solution for lesions previously considered inoperable without requiring a donor organ or immunosuppressants. The patient encountered multiple serious complications, including atrial fibrillation, deteriorated liver function, severe pulmonary infection, respiratory failure, and acute kidney injury (AKI). These complications necessitated intensive intraoperative and postoperative care, emphasizing the need for a comprehensive management strategy in such complicated high-risk surgeries.

CONCLUSIONS

The multidisciplinary collaboration in this case proved effective and yielded significant therapeutic outcomes for a rare case of advanced hepatic, cardiac, and pulmonary AE. The combined approach of ELRA and RA reconstruction under extracorporeal circulation demonstrated distinct advantages of ELRA in treating complex HAE. Meanwhile, assessing diaphragm function during the perioperative period, especially in patients at high risk of developing pulmonary complications and undergoing diaphragmectomy is vital to promote optimal postoperative recovery. For multi-resistant infection, it is imperative to take all possible measures to mitigate the risk of AKI if vancomycin administration is deemed necessary.

Clinical study of standard residual liver volume and transient elastography in predicting poor prognosis of patients after hemihepatectomy

BACKGROUND

Liver cancer resection, especially in patients with hemihepatectomy or extended hemihepatectomy, often leads to poor prognosis, such as liver insufficiency and even liver failure and death, because the standard residual liver volume (SRLV) cannot be fully compensated after surgery.

AIM

To explore the risk factors of poor prognosis after hemihepatectomy for hepatocellular carcinoma and evaluate the application value of related prognostic approaches.

METHODS

The clinical data of 35 patients with primary liver cancer in Nantong Third People's Hospital from February 2016 to July 2020 were retrospectively analyzed. The receiver operating characteristic curve was created using medcac19.0.4 to compare the critical values of the SRLV in different stages of liver fibrosis after hemihepatectomy with those of liver dysfunction after hemihepatectomy. It was constructed by combining the Child-Pugh score to evaluate its application value in predicting liver function compensation.

RESULTS

The liver stiffness measure (LSM) value and SRLV were associated with liver dysfunction after hemihepatectomy. Logistic regression analysis showed that an LSM value ≥ 25 kPa [odds ratio (OR) = 6.254, P < 0.05] and SRLV ≤ 0.290 L/m2 (OR = 5.686, P < 0.05) were independent risk factors for postoperative liver dysfunction. The accuracy of the new liver reserve evaluation model for predicting postoperative liver function was higher than that of the Child-Pugh score (P < 0.05).

CONCLUSION

SRLV and LSM values can be used to evaluate the safety of hemihepatectomy. The new liver reserve evaluation model has good application potential in the evaluation of liver reserve function after hemihepatectomy.

A novel remnant liver-first strategy for liver autotransplantation in patients with end-stage hepatic alveolar echinococcosis: a retrospective case series

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.

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.

Single-center experience of Ex vivo liver resection and autotransplantation for complex hepatic alveolar echinoccosis

OBJECTIVE

To summarize the single-centre experience of Ex vivo Liver Resection and Autotransplantation (ELRA) to treat end-stage hepatic alveolar echinococcosis (HAE).

METHODS

Retrospective analysis of clinical data and follow-up data of 13 patients admitted to the Affiliated Hospital of Qinghai University from January 2015 to December 1, 2020, with the Ex vivo Liver Resection and Autotransplantation for hepatic alveolar echinococcosis.

RESULT

13 patients underwent successful total/ semi-ex-vivo liver resection combined with Ex vivo Liver Resection and Autotransplantation with no intra-operative deaths. the median standard liver volume was 1,118 ml (1,085-1,206.5 ml); the median residual liver volume was 634 ml (526.5-1,338 ml); The median weight of the autograft was 845.8 g (619.5-1,020.5 g), the median operation time was 14.5 h (11.5-16.15 h); the median anhepatic period time was 290 min (257-312.5 min). The median intraoperative blood loss was 1,900 ml (1,300-3,500 ml); the median number of erythrocyte suspensions entered was 7.5 u (6-9u). The median length of hospital stay was 32 days (24-40 days). Postoperative complications occurred in 9 patients during hospitalization,with 7 patients graded at grade III or higher by Clavien-Dindo; 4 patients died postoperatively. 1 patient had recurrent abdominal distension with massive thoracoabdominal fluid and coagulation dysfunction 8 months after surgery and was considered to have small liver syndrome. 1 patient developed HAE recurrence during the follow-up, which was considered intraoperative incisional implantation.

CONCLUSION

ELRA is one of the most valuable therapeutic measures for the treatment of end-stage complicated hepatic alveolar echinococcosis. Precise preoperative assessment of liver function, individualized intraoperative duct reconstruction, and precise management of the postoperative disease can achieve better treatment results.

Application of WeChat-Utilized Mobile Health in Transitional Care Among Patients Undergoing Hepatectomy: A Pilot Study

This study aimed to investigate whether mobile health (mHealth)-based transitional care, which utilized WeChat, could benefit patients undergoing hepatectomy. From January 2019 to December 2020, 807 patients who underwent hepatectomy in a tertiary care hospital were included in the study. Patients were divided into a transitional care group (TC group) (n = 238) and a control group (n = 569) based on whether they participated in mHealth-based transitional care, which utilized the WeChat application. Depending on the type of variables, t-tests, χ² tests, and other statistical methods were used to compare differences between groups. Propensity score matching analysis was conducted for factors that differed in basic characteristics. After 1:1 matching, 238 patients were included in each group. Less readmission within 90 days of discharge, better quality of life, and higher satisfaction were found in the TC group both before and after matching (p < .05). This study showed the potential of applying mHealth-based transitional care among post-hepatectomy patients.

A Sarcopenia-Based Prediction Model for Postoperative Complications of ex vivo Liver Resection and Autotransplantation to Treat End-Stage Hepatic Alveolar Echinococcosis

Background

Sarcopenia and visceral adiposity have been shown to be associated with postoperative complications in numerous diseases. However, their effects on the postoperative complications of end-stage hepatic alveolar echinococcosis (HAE) patients undergoing ex vivo liver resection and autotransplantation (ELRA) remain unclear.

Methods

This retrospective study included 101 end-stage HAE patients who underwent ELRA from January 2014 to August 2020. We measured the skeletal muscle and adipose tissue of all patients at the level of the third lumbar vertebra on plain abdominal computed tomography (CT) images and subsequently derived an equation via least absolute shrinkage and selection operator (LASSO) regression analysis to calculate the sarcopenia score. Univariate and multivariate regression were performed to reveal the relationship between major postoperative complications and perioperative clinical data, and the obtained nomogram was validated with the bootstrapping method.

Results

The sarcopenia score was constructed as a personalized indicator to evaluate sarcopenia and visceral adiposity in each patient. Logistic regression analysis finally selected duration from primary diagnosis to obvious symptoms (OR=1.024, 95% CI, 1.007-1.042), surgical time (OR=1.003, 95% CI, 0.999-1.007) and sarcopenia score (OR=4.283, 95% CI, 1.739-10.551) as independent risk factors for predicting major postoperative complications following ELRA for end-stage HAE patients. The area under the receiver operating characteristic curve (AUROC) of 0.807 (95% CI, 0.720-0.895) and the calibration curve for this prediction model were satisfactory.

Conclusion

The sarcopenia score, which systematically evaluates the skeletal muscle and adipose tissue of end-stage HAE patients, was a significant predictive factor for major postoperative complications of ELRA. Relevant interventions should be conducted for those who have a high risk of postoperative complications according to the nomogram.

Ex vivo liver resection followed by autotransplantation in radical resection of gastric cancer liver metastases: A case report

BACKGROUND

Radical resection of gastric cancer liver metastases (GCLM) can increase the 5-year survival rate of GCLM patients. However, patients may lose the theoretical feasibility of surgery due to the critical location of liver metastasis in some cases.

CASE SUMMARY

A 29-year-old woman had a chief complaint of chronic abdominal pain for 1 year. Abdominal computed tomography and magnetic resonance imaging examinations suggested a mass of unknown pathological nature located between the first and second hila and the margin of the lower segment of the right lobe of the liver. The anterior wall of the gastric antrum was unevenly thickened. The diagnosis of (gastric antrum) intramucosal well-differentiated adenocarcinoma was histopathologically confirmed by puncture biopsy with gastroscopy guidance. She underwent radical resection (excision of both gastric tumors and ex vivo liver resection followed by autotransplantation simultaneously) followed by XELOX adjuvant chemotherapy. Without serious postoperative complications, the patient was successfully discharged on the 20^th day after the operation. Pathological examination of the excised specimen indicated that gastrectomy with D2 lymph node dissection for primary gastric tumors and R0 resection for liver metastases were achieved. The resected mass was confirmed to be poorly differentiated gastric carcinoma (hepatoid adenocarcinoma with neuroendocrine differentiation) with liver metastases in segments VIII. No recurrence or metastasis within the liver was found during a 7.5-year follow-up review that began 1 mo after surgery.

CONCLUSION

Application of ex vivo liver resection followed by autotransplantation in radical resection for GCLM can help selected patients with intrahepatic metastases located in complex sites obtain a favorable clinical outcome.

A new sarcopenia score prognostic for postoperative complications in hepatic alveolar echinococcosis: a multicenter retrospective study

Background

Skeletal muscle depletion and excessive visceral adipose tissue have been shown to be independent risk factors for postoperative complications (PCs) in various diseases. However, their impact on surgical PCs in hepatic alveolar echinococcosis (HAE) is still unknown.

Methods

We retrospectively reviewed the clinical data of HAE patients who underwent liver resection at our hospital between January 2008 and December 2018. We segmented skeletal muscle and adipose tissue and measured the area of skeletal muscle tissue and adipose tissue at the level of the third lumbar vertebra by manual tracing from preoperative plain computed tomography (CT) images. Sarcopenia features were selected to construct a formula based on the least absolute shrinkage and selection operator (LASSO) logistic regression model in the primary set. Then, integrating the results of multiple clinicopathologic characteristics, we built a nomogram for predicting major PCs in HAE. The results were validated using bootstrap resampling and clinical data from other HAE centers in western China.

Results

The sarcopenia score is based on the personalized levels of the five features from the primary set (n=233). In the multivariate logistic analysis of the primary set, the independent factors for PCs were γ-glutamyl transferase (GGT), and surface area of hepatectomy, which were integrated into the nomogram combined with sarcopenia score. The model had a good prediction capability with a C-index of 0.84 (95% CI, 0.72–0.96). The calibration plot for the probability of PCs showed an optimal agreement between the nomogram predictions and actual observations in the primary and validation sets.

Conclusion

Our study showed that sarcopenia score was significantly correlated with PCs in patients with HAE. In addition, we constructed a prognostic nomogram for predicting complications in HAE patients after liver surgery. The nomogram displayed excellent discrimination and calibration. Improving the nutritional status and physical health of patients before surgery might reduce the incidence of postoperative complications for the high-risk patients.

Outcomes of ex vivo liver resection and autotransplantation: A systematic review and meta-analysis

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.