Ex Vivo Liver Resection and Autotransplantation for End-Stage Alveolar Echinococcosis: A Case Series

Applying LASSO logistic regression for the prediction of biliary complications after ex vivo liver resection and autotransplantation in patients with end-stage hepatic alveolar echinococcosis

BACKGROUND

The purpose of this study was to explore the relevant risk factors associated with biliary complications (BCs) in patients with end-stage hepatic alveolar echinococcosis (HAE) following ex vivo liver resection and autotransplantation (ELRA) and to establish and visualize a nomogram model.

METHODS

This study retrospectively analysed patients with end-stage HAE who received ELRA treatment at the First Affiliated Hospital of Xinjiang Medical University between August 1, 2010 and May 10, 2023. The least absolute shrinkage and selection operator (LASSO) regression model was applied to optimize the feature variables for predicting the incidence of BCs following ELRA. Multivariate logistic regression analysis was used to develop a prognostic model by incorporating the selected feature variables from the LASSO regression model. The predictive ability, discrimination, consistency with the actual risk, and clinical utility of the candidate prediction model were evaluated using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). Internal validation was performed by the bootstrapping method.

RESULTS

The candidate prediction nomogram included predictors such as age, hepatic bile duct dilation, portal hypertension, and regular resection based on hepatic segments. The model demonstrated good discrimination ability and a satisfactory calibration curve, with an area under the ROC curve (AUC) of 0.818 (95% CI 0.7417-0.8958). According to DCA, this prediction model can predict the risk of BCs occurrence within a probability threshold range of 9% to 85% to achieve clinical net benefit.

CONCLUSIONS

A prognostic nomogram with good discriminative ability and high accuracy was developed and validated to predict BCs after ELRA in patients with end-stage HAE.

Kidney invasion occurred 2 years following liver transplantation for hepatic alveolar echinococcosis: a case report

BACKGROUND

The organ most commonly invaded in echinococcosis is the liver; the lungs, brain, kidneys, heart, and spleen are rarely invaded, and multi-organ involvement in echinococcosis is even rarer. No studies have reported renal invasion after liver transplantation for hepatic alveolar echinococcosis.

CASE PRESENTATION

We report here a case of renal invasion 2 years after allogeneic liver transplantation in a 53-year-old female patient with hepatic alveolar echinococcosis combined with lung metastases. At the time of the first consultation, the lesion had been found to involve the second hepatic hilum combined with lung metastases, but the patient requested conservative treatment, and the lesion was not controlled by taking albendazole for 3 years. After discussion in the treatment group, it was decided to use allogeneic liver transplantation and lung segmental resection for surgical treatment, after which the patient was put on long-term oral immunosuppression. She was hospitalized 2 years later for low back pain and diagnosed with renal alveolar echinococcosis. Due to significant compression and left-sided renal insufficiency, the final option was to remove the diseased kidney. It is worth mentioning that signs of unexplained urinary tract infection were present throughout the course of treatment.

CONCLUSION

This study suggests that extra attention should be paid to the presence of cryptogenic lesions in patients with hepatic alveolar echinococcosis who already have definite metastatic lesions. Immunosuppressive drugs after liver transplantation in patients with hepatic echinococcosis may cause occult lesions to develop into active ones. In clinical practice, particular attention should be paid to patients with hepatic alveolar echinococcosis with long-term concomitant signs of unexplained urinary tract infections, which may be a precursor clinical feature of cryptogenic renal alveolar echinococcosis.

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.

Complex inferior vena cava reconstruction during ex vivo liver resection and autotransplantation: A case report

BACKGROUND

Ex vivo liver resection and autotransplantation (ELRA) is an essential approach for treating patients with end-stage hepatic alveolar echinococcosis (AE), and its surgical indications involve severe invasion of important hepatic vessels, which makes in vivo resection impossible. Revascularization is a major step in the process of ELRA, which is extremely challenging when the invaded vessels have huge defects.

CASE SUMMARY

Herein, we have reported the case of a 26-year-old patient with hepatic AE in an autologous liver graft who underwent complex inferior vena cava (IVC) reconstruction using disease-free IVC, autologous portal vein fragments, and umbilical vein within the ligamentum teres hepatis. The patient showed good surgical recovery without vascular-related complications during the long-term follow-up.

CONCLUSION

We reviewed three studies that have reported complex revascularization of the IVC. This case report and systematic review showed that the use of autologous perihepatic vessels prevents donor-area trauma, immune rejection, and other adverse reactions. When the blood vessel is severely invaded and a single vascular material cannot repair and reconstruct the defect, ELRA may provide a safe and feasible surgical approach, which has good prospects for clinical application.

In vivo total or partial hepatectomy followed by ex vivo liver resection and autotransplantation for malignant tumors: a single center experience

Background

Ex vivo liver resection and autotransplantation (ELRAT) may provide an opportunity for R0 resection of conventionally unresectable hepatobiliary cancers and hepatic metastases. To date, few studies of the surgery for malignant tumors have been conducted and there are no known reports of in vivo partial hepatectomy followed by ELRAT (IPH-ELRAT) for malignant tumors.

Methods

Between December 2021 and November 2022, ten patients with malignant hepatobiliary primary cancers or hepatic metastases underwent ELRAT at our institution. We shared the surgical skills and postoperative prognoses of these patients were assessed.

Results

The types of tumors were biliary tract cancer (BTC, n=8), hepatic metastasis of colonic carcinoma (n=1), and hepatic metastasis of small-bowel stromal tumor (n=1). Five patients underwent in vivo total hepatectomy followed by ex vivo liver resection and autotransplantation (ITH-ELRAT), The other five received in vivo partial hepatectomy followed by ex vivo liver resection and autotransplantation (IPH-ELRAT). Four patients underwent inferior vena cava replacement using artificial blood vessels. The survival rate of all ten patients one month after surgery was 100%. Nine patients (90%) are currently alive, with a median follow-up of 8.5 months (range 6-16.5 months). To date, seven of the nine surviving patients have had no cancer recurrence, including six with BTC.

Conclusions

We report the world first five cases that received IPH-ELRAT for malignancies. We also demonstrated relatively favorable outcomes in patients who underwent ELRAT. ELRAT may be a recommendable surgical option for selected patients with conventionally unresectable hepatobiliary malignant tumors.

Differential Gene Expression Profiling in Alveolar Echinococcosis Identifies Potential Biomarkers Associated With Angiogenesis

Background

Alveolar echinococcosis (AE) is a worldwide zoonosis caused by Echinococcus multilocularis. Alveolar echinococcosis is a severe chronic parasitic disease that exhibits a tumor-like growth, with the potential for invasion and distant metastasis; however, the molecular mechanism underlying this condition remains unclear.

Methods

Transcriptome analyses were performed to detect differentially expressed genes (DEGs) in samples from patients with AE with invasion and distant metastasis. The results were further verified by immunohistochemistry.

Results

A total of 1796 DEGs were identified, including 1742 upregulated and 54 downregulated DEGs. A subsequent functional analysis showed that the significant DEGs were involved in the angiogenesis process. Immunohistochemical analysis confirmed the reliability of the transcriptomic data.

Conclusions

These results suggest that angiogenesis is a possible mechanism underlying the tumor-like biological behavior observed during E multilocularis infection. Genes related to this process may play important roles in AE invasion and distant metastasis.

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.

Approaches to reconstruction of inferior vena cava by ex vivo liver resection and autotransplantation in 114 patients with hepatic alveolar echinococcosis

BACKGROUND

Hepatic alveolar echinococcosis (AE) is most commonly found in retrohepatic inferior vena cava (RHIVC). Ex vivo liver resection and autotransplantation (ELRA) can better realize the radical resection of end-stage hepatic AE with severely compromised hepatocaval confluences, and reconstruction of the affected vessels. Currently, there is a scarcity of information regarding RHIVC reconstruction in ELRA.

AIM

To propose reasonable RHICV reconstruction strategies for ex vivo liver resection and autotransplantation.

METHODS

We retrospectively summarized the clinical data of 114 patients diagnosed with hepatic AE who treated by ELRA in our department. A total of 114 patients were divided into three groups according to the different reconstruction methods of RHIVC: Group A with original RHIVC being repaired and reconstructed (n = 64), group B with RHIVC being replaced (n = 43), and group C with RHIVC being resected without reconstruction (n = 7). The clinical data of patients, including the operation time, anhepatic phase, intraoperative blood loss, complications and postoperative hospital stay, were analyzed and the patients were routinely followed up. The normally distributed continuous variables were expressed as means ± SD, whereas the abnormally distributed ones were expressed as median and analyzed by analysis of variance. Survival curve was plotted by the Kaplan-Meier method.

RESULTS

All patients were routinely followed up for a median duration of 52 (range, 12-125) mo. The 30 d mortality rate was 7.0% (8/114) and 7 patients died within 90 d. Among all subjects, the inferior vena cava (IVC)-related complication rates were 17.5% (11/63) in group A and 16.3% (7/43) in group B. IVC stenosis was found in 12 patients (10.5%), whereas thrombus was formed in 6 patients (5.3%). Twenty-two patients had grade III or higher complications, with the complication rates being 17.2%, 16.3%, and 57.1% in the three groups. The average postoperative hospital stay in the three groups was 32.3 ± 19.8, 26.7 ± 18.2, and 51.3 ± 29.4 d (P = 0.03), respectively.

CONCLUSION

ELRA can be considered a safe and feasible option for end-stage hepatic AE patients with RHIVC infiltration. The RHIVC reconstruction methods should be selected appropriately depending on the defect degree of AE lesions in IVC lumen. The RHIVC resection without any reconstruction method should be considered with caution.

From liver surgery to liver transplant surgery: new developments in autotransplantation

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.

Current indications of ex-situ liver resection: A systematic review

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.

Laparoscopic Treatment Strategies for Liver Echinococcosis

Liver echinococcosis is clinically mainly composed of hepatic cystic echinococcosis (CE) and hepatic alveolar echinococcosis (AE). At present, laparoscopy has been comprehensively applied in the treatment of two types of liver echinococcosis. For hepatic CE treatment, both laparoscopic total pericystectomy and laparoscopic hepatectomy can achieve radical results, but the former is considered the first choice owing to its being more minimally invasive; laparoscopic subtotal pericystectomy and laparoscopic partial pericystectomy can be accepted as complementary options, considering the presence of complicated cysts and the level of laparoscopic technique in remote hospitals; laparoscopic cystectomy is simple, but it is not currently recommended for treatment of hepatic CE owing to poor efficacy and high risk of postoperative complications. For hepatic AE treatment, laparoscopy not only achieves the same radical effect as open surgery in selected patients, but also is more minimally invasive, so it has a better prospect.

Regional anticoagulation magnetic artificial blood vessels constructed by heparin-PLCL core-shell nanofibers for rapid deployment of veno-venous bypass

Veno-venous bypass (VVB) is necessary for maintaining hemodynamic and internal environment stabilities in complex liver surgeries. However, the current VVB strategies require systematic anticoagulation and are time-consuming, leading to unexpected complications. This study aims to overcome these limitations by using a novel magnetic artificial blood vessel constructed with heparin-PLCL core-shell nanofibers. Coaxial electrospinning was used to fabricate core-shell nanofibers with heparin encapsulated into the core layer. The microstructure, physical and chemical properties, hemocompatibility, and heparin release behavior were characterized. The regional anticoagulation magnetic artificial vessel was constructed with these nanofibers and used to perform VVB in a rat liver transplantation model for in vivo evaluation. The core-shell nanofibers appeared smooth and uniform without apparent defects. Fluorescence and TEM images indicated that heparin was successfully encapsulated into the core layer. In addition, the in vitro heparin release test presented a two-phase release profile, burst release at day 1 and sustained release from days 2 to 14, which resulted in better hemocompatibility. The VVB could be rapidly deployed in 3.65 ± 0.83 min by the magnetic artificial vessel without systemic anticoagulation. Moreover, the novel device could reduce portal pressure and abdominal organ congestion, protect intestinal function, and increase the survival rate of liver transplantation with a long anhepatic phase from 0 to 65%. In summary, VVB can be rapidly deployed using regional anticoagulation magnetic artificial blood vessels without systemic anticoagulation, which is promising for improving patient outcomes after complex liver surgery.

Reconstruction of hepatic venous outflow and management of its complications using ex vivo liver resection and autotransplantation: a single-center experience

BACKGROUND

This study was designed to investigate the techniques of hepatic venous outflow reconstruction and the management of its complications using ex vivo liver resection and autotransplantation (ELRA).

METHODS

Being a retrospective case series covering 84 patients who underwent hepatic venous outflow reconstruction during ELRA from January 2016 to October 2020, 11 cases of postoperative hepatic venous outflow obstruction (HVOO), whose surgery details were described and survival rates analyzed.

RESULTS

A total of the 84 alveolar Echinococcosis (AE) series was no intraoperative death. The 30-day mortality was 5.95% (5 /84). The most common postoperative complication was pleural effusion in 21 cases (25%). HVOO occurred in 11 cases, one of them died of liver failure, and the other 10 patients underwent interventional revascularization with good results. There was no significant difference in survival between patients with successful interventional revascularization due to HVOO and patients without HVOO (P > 0.05).

CONCLUSIONS

Individualized and well design reconstruction of hepatic vein can be considered as a key procedure to reduce the complications of HVOO in ELRA. Once HVOO occurs, emergent management must be performed immediately before liver dysfunction. Interventional revascularization showed an effective approach, though the more clinical cases need to be evaluated.

Triphase contrast-enhanced CT to evaluate indications for autologous liver transplantation in patients with end-stage hepatic alveolar echinococcosis

Autologous liver transplantation (ALT) to cure end-stage hepatic alveolar echinococcosis (HAE) requires that hepatobiliary surgeons understand the invasion of intrahepatic structure and adjacent tissues or organs. Triphase contrast-enhanced CT of the liver has been widely used for diagnosis and preoperative evaluation of HAE. Three-dimensional (3D) reconstruction allows for accurate measurement of remnant liver volume (RLV). The objective of the study was to evaluate value of triphase contrast-enhanced CT together with 3D reconstruction in preoperative evaluation of indications for ALT in patients with end-stage HAE. This cohort include twenty-one consecutive patients with end-stage HAE, who preoperatively underwent triphase enhanced CT together with 3D reconstruction for ALT. To depict the indications, the 2D image data were reviewed statistically focusing on porta hepatis invasion, retrohepatic vena cava (RHVC) involvement and degrees of intrahepatic vessel invasion, and the 3D reconstruction was performed to obtain ratio of RLV to standard liver volume (SLV). The results showed that 95.24% patients (20/21) had porta hepatis invasion. When lesions located in right liver lobe, porta hepatis invasion occurred most commonly in the second and third porta hepatis (7/10), whereas the first, second and third porta hepatis were most commonly invaded by lesions in the right and caudate / left medial liver lobes (7/11) (P < 0.05). The mean value of longitudinal invasion of RHVC was 8.0 cm, and 95.2% (20/21) of patients had RHVC invasion with ≥ 180° circumferential invasion. As for the important vascular events, moderate and severe invasion occurred most commonly in the right hepatic vein, right branch of portal vein and RHVC each in 95.2% (20/21) patients (P < 0.05). We also found that preoperative CT had a good agreement with intraoperative findings in assessing intrahepatic vascular involvement by HAE (kappa index = 0.77). The estimated average ratio of RLV to SLV was 0.95 (range, 0.43–1.62). In conclusion, the 2D contrast-enhanced CT could well depict anatomic location and size of HAE, and invasion of porta hepatis and vascular by this disease, and involvement of other adjacent organs and tissues. Above all, 3D reconstruction could accurately measure RLV in patients with end-stage HAE for ALT.

Application of ex vivo liver resection and autotransplantation in treating Budd-Chiari syndrome secondary to end-stage hepatic alveolar echinococcosis: A case series

BACKGROUND

Secondary Budd-Chiari syndrome (BCS) occurs due to a blockage in the liver caused by invasion or compression by a large lesion. Conventional treatments for BCS do not solve practical problems, wherease liver transplantation has been only applied as a last-resort therapy and as the only opportunity for a radical cure. We explored the feasibility of applying ex vivo liver resection and autotransplantation (ELRA) for the new indications of treating patients with end-stage hepatic alveolar echinococcosis (HAE). Our center has firstly proposed the idea and successfully treated the 49 patients with HAE. This article for the first time reports the application of ELRA in treating patients with BCS secondary to HAE.

METHODS

According to the degree of lesion invasion and surgical options, 11 patients were divided into 4 types. These 11 patients had large lesions that invaded the second and third hilum of the caudate lobe and involved the confluence of the hepatic vein and the inferior vena cava, suprahepatic vena cava, or at least 2 hepatic veins and led to secondary BCS. The aim of the present work was to report 11 patients with life-threatening diseases who underwent ELRA (ex vivo liver resection and autotransplantation) for secondary BCS, to propose a classification system for secondary BCS, and to suggest that secondary BCS is an indication for ELRA.

RESULTS

Eleven patients successfully underwent ELRA without intraoperative mortality. The median autograft weight was 690 g (440-950 g); operative time was 12.5 hours (9.4-16.5 hours); Postoperative hospital stay was 15 days (7-21 days). Clavien-Dindo grade IIIa or higher postoperative complications occurred in only 5 patients.

CONCLUSIONS

This article for the first time reports the application of ELRA in treating patients with BCS secondary to HAE, not only provides new ideas for alternative treatments of secondary BCS, but also provides a classification system for secondary BCS. This article describes the technical process of outflow tract reconstruction and the experience for expanding the indications for ELRA. Our study demonstrated that ELRA is well feasible for treatment of BCS secondary to advanced HAE.

Ex Vivo Liver Resection and Autotransplantation as Surgical Option for Zone II-III Leiomyosarcoma of IVC: A Case Report and Literature Review

We report the first documented case of leiomyosarcoma at zone II-III of inferior vena cava with thrombi in three hepatic veins undergoing ex vivo liver resection and autotransplantation (ELRA) and hepatic veins thrombectomy. A 33-year-old female patient presented with abdominal distention and lower extremities edema. Abdominal wall varicosis and shifting dullness were positive on physical examination. Her liver function was classified as Child-Pugh B and a solid tumor at retro-hepatic vena cava extending to right atrium with thrombi in three hepatic veins were confirmed. The diagnosis of leiomyosarcoma with Budd-Chiari syndrome was highly suspected with preoperative ultrasound, echocardiogram, CT scan, and three-dimensional reconstruction. A zone II-III leiomyosarcoma of IVC origin was confirmed at surgery and ex vivo liver resection and autotransplantation, and hepatic vein thrombectomy with atrial reconstruction were performed under cardiopulmonary bypass (CPB). Operative time, anhepatic time, and CPB time were 12 h, 128 min, and 84 min, respectively. The patients experienced post-operative liver dysfunction and was cured with conservative therapy. Hepatic recurrence two years after surgery was managed with radiofrequency. The patient was alive with liver metastasis three years after surgery. Despite being regarded as an extremely aggressive procedure, ELRA could be considered in the treatment of advanced leiomyosarcoma with Budd-Chiari syndrome and hepatic vein thrombi.

Atrial reconstruction, distal gastrectomy with Ante-situm liver resection and autotransplantation for hepatocellular carcinoma with atrial tumor thrombus: A case report

RATIONALE

Hepatocellular with tumor thrombi extending into 3 hepatic veins (HVs) and right atrium presents as a real clinical challenge. We report the first documented case of surgical resection of an advanced hepatocellular carcinoma (HCC) with extensive invasion to distal stomach, atrium and hepatic vasculatures.

PATIENT CONCERNS

We present a case of 48-years old man with abdominal mass accompanying shortness of breath after activities.

DIAGNOSES

Preoperative examination revealed giant HCC with tumor thrombi extending into portal vein, HVs, inferior vena cava, and atrium.

INTERVENTIONS

Distal stomach involvement was confirmed at surgery and, distal gastrectomy, atrial reconstruction and ante-situm liver resection and autotransplantation under cardio-pulmonary bypass were performed.

OUTCOMES

The operation time was 490 minutes, extracorporeal circulation time 124 minutes, and anhepatic time 40 minutes. Postoperative follow-up revealed normal hepatic and cardiac function with no sign of recurrence.

LESSONS

This case illustrates that the extensive invasion of HCC to major vasculature and adjacent organs may not necessarily preclude the liver autotransplantation with multi-visceral resection as the treatment option of extremely advanced HCC patients.

Use of the ligamentum teres hepatis for outflow reconstruction during ex vivo liver resection and autotransplantation in patients with hepatic alveolar echinococcosis: A case series of 24 patients

BACKGROUND

Patients with extensive hepatic alveolar echinococcosis might require ex vivo liver resection and autotransplantation to remove the lesion. Patients with extensive vascular invasion will need reconstruction, but the selection of the proper graft is complicated. This study aimed to investigate the effectiveness and adverse events of using the ligamentum teres hepatis as a vascular replacement graft in ex vivo liver resection and autotransplantation.

METHODS

This was a retrospective case series of patients with hepatic alveolar echinococcosis who underwent ex vivo liver resection and autotransplantation between August 2010 and October 2018 and in whom the ligamentum teres hepatis was used to repair the remnant liver. The operative outcomes, recurrence, and survival were examined.

RESULTS

Twenty-four patients were included (10 men, 14 women). The anhepatic period was 290 to 672 minutes (median of 450 minutes). The ratio of the remnant liver volume to the standard liver volume was 0.43 to 0.97 (median of 0.71). The blood loss was 1,000 (500-5,000) mL. The postoperative hospital stay was 23 (1-85) days. Of the 24 patients, 3 died after the operation, but those deaths were unrelated to liver vascular complications.

CONCLUSION

The ligamentum teres hepatis could be used as a vascular replacement graft in ex vivo liver resection and autotransplantation. It has the advantages of convenient specimen extraction, no donor site injury, and no immunological rejection, which has promising clinical application prospects.

Laparoscopic or open treatment for hepatic alveolar echinococcosis: A single-institution experience

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of laparoscopy in the treatment of hepatic alveolar echinococcosis (AE).

METHODS

Between January 2018 and December 2019, 213 hepatic AE patients were admitted to the authors' institution. Among them, 165 patients (77.46%, 165/213) underwent surgery. Of 13 patients who underwent laparoscopic treatment, two required conversion to open surgery. The remaining 11 patients (group 1) were analyzed. During the same period, 154 patients underwent open surgery, but only 14 records were compatible with the criteria for the laparoscopic approach and were reviewed retrospectively (group 2).

RESULTS

Conversion to open surgery occurred in two cases. Both groups were basically consistent in terms of detailed demographic data, characteristics of the lesions, and surgical strategy (P > 0.05). The laparoscopic group not only achieved the same R0 resection as the open group, but the results were also significantly superior to those of the open group in terms of postoperative complications, postoperative catheterization time, and postoperative hospital stay (P = 0.042, P = 0.046, and P = 0.045, respectively). No recurrences were observed in either group during this period.

CONCLUSIONS

Laparoscopic surgery provides a safe and efficacious approach for hepatic AE in selected patients. Large, prospective, randomized trials are needed to confirm its superiority.

The technical aspects of ex vivo hepatectomy with autotransplantation: a systematic review and meta-analysis

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.

Laparoscopic hepatectomy for the treatment of hepatic alveolar echinococcosis

Background: At present, laparoscopy is relatively mature as a minimally invasive technique, but there are few reports on this approach for the radical treatment of hepatic alveolar echinococcosis (AE). In this study, we aimed to evaluate the safety and feasibility of laparoscopic hepatectomy (LH) for AE treatment. Results: A retrospective review of medical records obtained from 13 patients diagnosed with AE between January 2018 and December 2019 and treated with laparoscopic hepatectomy was conducted at the First Affiliated Hospital of Xinjiang Medical University. All patients (n = 13) underwent hepatic resection using laparoscopy and none were transferred to open surgery. The average duration of surgery was 285 min (145–580 min). Intraoperative bleeding was 305 mL (20–2000 mL). The mean duration of postoperative catheterization was 6.9 days (3–21 days), and postoperative hospital stay was 7.2 days (4–14 days). No complication of Clavien-Dindo grade III or above occurred, except for the second patient with acute liver failure post-surgically. No recurrences or deaths were observed at 9–30 months of follow-up. Conclusions: Laparoscopic hepatectomy appears to be safe and effective in selected AE patients. The advantages of this technique for AE treatment need to be further compared with the classical open approach.

Nutritional status and screening tools to detect nutritional risk in hospitalized patients with hepatic echinococcosis

Background: Echinococcosis is a chronic consumptive liver disease. Little research has been carried out on the nutritional status of infected patients, though liver diseases are often associated with malnutrition. Our study investigated four different nutrition screening tools, to assess nutritional risks of hospitalized patients with echinococcosis. Methods: Nutritional Risk Screening 2002 (NRS 2002), Short Form of Mini Nutritional Assessment (MNA-SF), Malnutrition Universal Screening Tool (MUST), and the Nutrition Risk Index (NRI) were used to assess 164 patients with alveolar echinococcosis (AE) and 232 with cystic echinococcosis (CE). Results were then compared with European Society for Clinical Nutrition and Metabolism (ESPEN) criteria for malnutrition diagnosis. Results: According to ESPEN standards for malnutrition diagnosis, 29.2% of CE patients and 31.1% of AE patients were malnourished. The malnutrition risk rates for CE and AE patients were as follows: NRS 2002 – 40.3% and 30.7%; MUST – 51.5% and 50.9%; MNA-SF – 46.8% and 44.1%; and NRI – 51.1% and 67.4%. In patients with CE, MNA-SF and NRS 2002 results correlated well with ESPEN results (k = 0.515, 0.496). Area-under-the-curve (AUC) values of MNA-SF and NRS 2002 were 0.803 and 0.776, respectively. For patients with AE, NRS 2002 and MNA-SF results correlated well with ESPEN (k = 0.555, 0.493). AUC values of NRS 2002 and MNA-SF were 0.776 and 0.792, respectively. Conclusion: This study is the first to analyze hospitalized echinococcosis patients based on these nutritional screening tools. Our results suggest that NRS 2002 and MNA-SF are suitable tools for nutritional screening of inpatients with echinococcosis.

Ex Vivo Resection and Autotransplantation for Conventionally Unresectable Tumors - An 11-year Single Center Experience

BACKGROUND AND AIMS

Ex vivo surgery may provide a chance at R0 resection for conventionally unresectable tumors. However, long-term outcomes have not been well documented. In this study, we analyze our 11-year outcomes to define its role.

STUDY DESIGN

We retrospectively analyzed 46 consecutive patients who underwent ex vivo surgery at our institution 2008-2019.

RESULTS

The types of tumors were: carcinoma (n = 20), sarcoma (n = 20) and benign to low grade tumor (n = 6). The type of ex vivo surgery was chosen based on tumor location and vascular involvement. The most commonly performed procedure was ex vivo hepatectomy (n = 18), followed by ex vivo resection and intestinal autotransplantation (n = 12), ex vivo Whipple procedure and liver autotransplantation (n = 8) and multivisceral ex vivo procedure (n = 7). Twenty-three patients (50%) are currently alive with median follow-up of 4.0-years (11 months-11.8 years). The overall survival was 70%/59%/52%, at 1-/3-/5-years, respectively. Patient survival for benign to low grade tumors, sarcoma, and carcinoma was 100%/100%/100%, 65%/60%/50%, and 65%/45%/40%, at 1-/3-/5-years, respectively. Ninety-one percent patients had R0 resection, and 57% had no recurrence to date with median follow-up of 3.1-years. Two patients (4.3%) died within 30 days due to sepsis and gastroduodenal artety (GDA) stump blowout. Two additional patients died between 30 and 90 days due to sepsis. Perioperative mortality in the last 23 consecutive cases was limited to 1 patient who died of sepsis between 30 and 90 days.

CONCLUSIONS

For a selected group of patients with conventionally unresectable tumors, ex vivo surgery can offer effective surgical removal with a reasonably low perioperative mortality at experienced centers.

Feasibility of Retrohepatic Inferior Vena Cava Resection Without Reconstruction for Hepatic Alveolar Echinococcosis

This study evaluates the feasibility of retrohepatic inferior vena cava (RHIVC) resection without reconstruction in patients with end-stage hepatic alveolar echinococcosis (AE). Four hundred and fifty-seven patients diagnosed with hepatic AE and who underwent surgical resections between January 2010 and October 2018 were retrospectively analyzed. Nine patients receiving RHIVC resection without reconstruction were included in this study. Among the patients, 5 were male and 4 female. Mean follow-up time was 64.4 months (18-95). In this series, adequate collateral circulation was formed before operation in all patients, and 7 cases underwent ex vivo liver resection and autotransplantation (ELRA) and 2 cases underwent extended right hemi-hepatectomy. Average standard liver volume, graft volume, surgical time, and anhepatic phase in ELRA group patients was 1144 ± 127 cm³, 740 ± 235 cm³, 16.8 ± 4.1 hours, and 337.4 ± 108.65 minutes respectively. Average hospital stay time for all patients was 45 ± 36.4 days. There were no intraoperative deaths. The 30-day mortality rate was 11.1%, and total mortality rate was 22.2%. Postoperative complications occurred in 4 patients. During follow-up, no relapsed AE lesions were found. RHIVC resection without reconstruction is a feasible way for hepatic AE patients with adequate collateral circulation. Careful protection of collateral venous is the key factor for successful operation.

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.

Current trends in vena cava reconstructive techniques with major liver resection: a systematic review

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.

Individualized biliary reconstruction techniques in autotransplantation for end-stage hepatic alveolar echinococcosis

BACKGROUND

Biliary reconstruction in ex vivo liver resection followed by autotransplantation (ERAT) for end-stage hepatic alveolar echinococcosis (HAE) remains the most challenging step, we present our experience with this complex procedure.

METHODS

A retrospective data analysis of 55 patients with end-stage HAE underwent ERAT, the biliary reconstruction techniques and short- and long-term outcomes were discussed.

RESULTS

All autografts were derived from the left lateral section after extensive ex vivo liver resection, multiple bile ducts were observed in 52 (94.5%) patients, and forty-four (80.0%) cases required ductoplasty. Biliary reconstruction was achieved with duct-to-duct anastomosis in 32 (58.2%) patients, Roux-en-Y hepaticojejunostomy (RYHJ) in 14 (25.5%) patients, and a combination of the two methods in 9 (16.4%) patients. Twenty (36.4%) patients had multiple anastomoses. Biliary leakage occurred in 8 (14.5%) patients postoperatively. Three (5.5%) patients died of liver failure, cerebral hemorrhage and intraabdominal bleeding. During a median of 31 months followed-up time, 3 (5.5%) patients developed anastomotic stricture, 1 of whom was treated by repeat RYHJ, while the others were managed with stenting.

CONCLUSIONS

With a well-designed plan and precise anastomosis, complex biliary reconstruction in ERAT can be performed with few biliary complications by a professional team.

In situ reconstruction of vascular inflow/outflow to left lateral liver section, ex-vivo liver resection and autologous liver transplantation of remaining liver remnant for hepatic alveolar echinococcosis

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Advanced HAE treated with the modified technique of ex vivo liver resection and autologous liver transplantation.

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The in situ reconstruction of the vascular inflow/outflow of left lateral liver section maintained the PV circulation.

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The subsequent autologous right liver transplantation provided additional liver functional tissues, thus reduced the risk of liver failure.

•

This surgical procedure did not require any veno-venous bypass.

Objective

This is a case report on a patient with advanced hepatic alveolar echinococcosis (HAE) treated with autologous liver transplantation without any veno-venous bypass using the modified technique of ex vivo liver resection and autologous liver transplantation (the ERAT technique).

Method

A 27-year old male with advanced HAE underwent in situ reconstruction of vascular inflow/outflow to left lateral liver section, ex-vivo liver resection and autologous liver transplantation of remaining liver remnant (the modified ERAT technique). The operation consisted of hepatotomy along the right border of the falciform ligament, reconstruction of portal vein supplying the left lateral liver section, reconstruction of left hepatic vein, followed by removal of liver segments S1, S4 to S8, ex vivo resection of all involved tissues within these liver segments in the liver remnant, and autologous liver transplantation of the resected liver remnant. The whole surgical procedure lasted for 12 h, and the blood lost was 800 mL. The patient recovered uneventfully in the post-operation period.

Conclusion

The in situ reconstruction of the vascular inflow/outflow of left lateral liver section maintained the PV circulation and provided liver functional support during the operation. The subsequent autologous liver transplantation provided additional liver functional tissues, thus reduced the risk of post-hepatectomy liver failure. This surgical procedure did not require any veno-venous bypass.

Percutaneous stenting of left hepatic vein followed by Ex vivo Liver Resection and Autotransplantation in a patient with hepatic alveolar echinococcosis with Budd-Chiari syndrome

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A metal mesh stent was placed in the left hepatic vein of a 45-year-old man who presented with Budd-Chiari syndrome in stage 1.

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After disappearance of ascites and improvement in liver function, ELRA was performed in stage 2.

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Follow-up examination at 6 months showed normal liver function and no evidence of recurrence.

•

In selected patients with Budd-Chiari syndreme, percutaneous stenting followed by ELRA represent an curative treatment option.

Background and aims

Infiltration of hepatic venous outflow in hepatic alveolar echinococcosis can lead to development of Budd-Chiari syndrome. Medical treatment of this condition is generally unsatisfactory. Radical hepatic resection is impossible for extensive parasitic involvement of liver. This is a case report on a patient who was successfully treated with percutaneous stenting of left hepatic vein followed by Ex vivo Liver Resection and Autotransplantation (ELRA).

Methods

Using the transjugular approach, a metal mesh stent was placed in the left hepatic vein of a 45-year-old man who presented with Budd-Chiari syndrome. After disappearance of ascites and improvement in liver function, Ex vivo Liver Resection and Autotransplantation were performed.

Results

The patient underwent left hepatic vein stenting for Budd-Chiari syndrome without complication. Three months later, liver biopsy showed fibrous proliferation of interlobular portal areas and normal hepatic lobules. After successful Ex vivo Liver Resection and Autotransplantation, follow-up examination at 6 months showed normal liver function and no evidence of recurrence.

Conclusions

Allotransplantation is an accepted treatment for advanced hepatic alveolar echinococcosis with Budd-Chiari syndrome. However, shortage of organ donors and need for immunosuppression are challenging problems. In selected patients with hepatic vein stenoses presenting as Budd-Chiari syndreme, percutaneous stenting of hepatic veins followed by ex vivo liver resection and autotransplantation represent an alternative curative treatment option.

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

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.

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

BACKGROUND

The successful application of ex vivo liver resection and autotransplantation (ERAT) has gained widespread attention for the treatment of end-stage hepatic alveolar echinococcosis, which is considered to be unresectable by conventional methods due to extensive invasion of the extra- and intrahepatic vasculature. However, data on remnant liver volume (RLV) are limited, and the safe volume limit of remnant liver is still unclear.

METHODS

To determine the effect of liver volume in the technically developed era, we investigated the impact of the remnant liver-to-standard liver volume ratio (RLV/SLV) on the outcomes of ERAT.

RESULTS

From February 2014 to May 2018, 56 ERAT procedures were performed. Eleven patients with an RLV/SLV < 40% (group S) were compared with 45 patients with an RLV/SLV ≥ 40% (group L). Serial changes in postoperative serum total bilirubin, alanine aminotransferase, aspartate aminotransferase, and international normalized ratio were comparable in both groups. The incidences of postoperative complications did not significantly differ between the two groups. Three patients died of intra-abdominal bleeding, acute cerebral hemorrhage, and severe liver dysfunction. In RLV estimation analysis, the actual RLV and RLV/SLV were significantly smaller than the expected RLV and RLV/SLV as determined by preoperative three-dimensional reconstruction software in patients with hepatic venous outflow obstruction.

CONCLUSION

Patients with a smaller RLV/SLV did not have outcomes inferior to those with a larger RLV/SLV. Further studies are warranted to clarify the factors that contribute to preoperative volumetric estimation and the safe lower limits for ERAT.

Outcomes of different surgical resection techniques for end-stage hepatic alveolar echinococcosis with inferior vena cava invasion

BACKGROUND

Hepatic alveolar echinococcosis (HAE) lesions with inferior vena cava (IVC) invasion require combined resection of the liver and IVC. The outcomes of different surgical treatments, including in situ, ante situm and ex vivo resection, remain unclear.

METHODS

A total of 71 consecutive HAE patients who underwent hepatectomy with retrohepatic IVC resection were included. The patients were divided into ex vivo liver resection and autotransplantation (ERAT) group (n = 45) and in vivo resection group (n = 26). These techniques were assessed for feasibility and short- and long-term outcomes.

RESULTS

There were no significant differences with respect to postoperative complications and mortality between the ERAT and in vivo resection groups. The causes of mortality were liver failure in 3 patients, hemorrhagic shock in 1 patient, intra-abdominal bleeding in 1 patient, and acute cerebral hemorrhage in 1 patient. During a median of 22 months followed-up time, 2 patients developed ascites because of venous outflow stenosis, and 1 patient developed biliary stenosis in the ERAT group. The distant metastasis, local recurrence, and mortality rates were 0%, 1.4%, and 8.5%, respectively.

CONCLUSION

Combined liver resection and reconstruction of the IVC can be safely performed in selected patients with in situ, ante situm, and ex vivo resection.

Surgical approaches for definitive treatment of hepatic alveolar echinococcosis: results of a survey in 178 patients

Hepatic alveolar echinococcosis (HAE) is a potentially fatal disease caused by the larval growth of Echinococcus multilocularis. We analysed the clinical data of 178 consecutive HAE patients treated with definitive radical surgery at our institution. According to the surgical approach: group A patients underwent direct radical hepatic resection; group B patients first underwent percutaneous puncture external drainage, followed by radical hepatic resection 2 months later; group C patients underwent a two-step hepatic resection; and group D patients underwent liver transplantation. The baseline characteristics, mortality, postoperative complications and recurrence rates were evaluated. Symptoms were present in 79.8% (142/178) patients. Bi-lobar lesion was found in 34 (19.1%, 34/178) patients, 47.2% (84/178) of whom had ⩾2 lesions each. There were no intraoperative deaths. The postoperative mortality was 2.29% in group A, 8.62% in group D and 0% in groups B and C. The main cause of death was a serious postoperative complication (Clavien–Dindo grades III–V). Patients were followed-up systematically for a median of 35.8 months (8–72) without recurrence. Active HAE should be treated by radical liver resection, and the complicated alveolar echinococcosis of the liver has been managed whenever possible using principles of radical liver resection by experienced hepatic surgeons.

The dawn of liver perfusion machines

PURPOSE OF REVIEW

Despite high demand, a severe shortage of suitable allografts limits the use of liver transplantation for the treatment of end-stage liver disease. The transplant community is turning to the utilization of high-risk grafts to fill the void. This review summarizes the reemergence of ex-vivo machine perfusion for liver graft preservation, including results of recent clinical trials and its specific role for reconditioning DCD, steatotic and elderly grafts.

RECENT FINDINGS

Several phase-1 clinical trials demonstrate the safety and feasibility of machine perfusion for liver graft preservation. Machine perfusion has several advantages compared with static cold storage and may provide superior transplantation outcomes, particularly for marginal grafts. Ongoing multicenter trials aim to confirm the results of preclinical and pilot studies and establish the clinical utility of ex-vivo liver machine perfusion.

SUMMARY

Mounting evidence supports the benefits of machine perfusion for preservation of liver grafts. Thus, machine perfusion is a promising strategy to expand the donor pool by reconditioning and assessing viability of DCD, elderly and steatotic grafts during the preservation period. Additionally, machine perfusion will serve as a platform to facilitate graft intervention and modification to further optimize marginal grafts.

Echinococcosis: Advances in the 21st Century

Echinococcosis is a zoonosis caused by cestodes of the genus Echinococcus (family Taeniidae). This serious and near-cosmopolitan disease continues to be a significant public health issue, with western China being the area of highest endemicity for both the cystic (CE) and alveolar (AE) forms of echinococcosis. Considerable advances have been made in the 21st century on the genetics, genomics, and molecular epidemiology of the causative parasites, on diagnostic tools, and on treatment techniques and control strategies, including the development and deployment of vaccines. In terms of surgery, new procedures have superseded traditional techniques, and total cystectomy in CE, ex vivo resection with autotransplantation in AE, and percutaneous and perendoscopic procedures in both diseases have improved treatment efficacy and the quality of life of patients. In this review, we summarize recent progress on the biology, epidemiology, diagnosis, management, control, and prevention of CE and AE. Currently there is no alternative drug to albendazole to treat echinococcosis, and new compounds are required urgently. Recently acquired genomic and proteomic information can provide a platform for improving diagnosis and for finding new drug and vaccine targets, with direct impact in the future on the control of echinococcosis, which continues to be a global challenge.

Transhepatic-intrahepatic branches of the portal vein catheterization for ex vivo liver resection and autotransplantation: Two case reports of novel approach to perfuse the liver

RATIONALE

There has been increased use of ex vivo liver resection and autotransplantation (ERAT) for treatment of end-stage hepatic alveolar echinococcosis (HAE). Rapid perfusion of the autograft in bench resection is always required to reduce the warm ischemia time (WIT) and to protect the function of the remnant liver. Nevertheless, the severe invasion of the portal hepatis sometimes makes it impossible to find a usable inflow rapidly and the process of perfusion could be delayed.

PATIENT CONCERNS

Two patients diagnosed with end-stage HAE combined with severe portal hepatis invasion were selected to undergo ERAT at our center.

DIAGNOSIS

Besides the large HAE lesions, the CT imaging of patient 1 showed that part of the intra- and extrahepatic portal vein (PV) had disappeared. Patient 2 had severe invasion of both of the right and left branches of the PV.

INTERVENTIONS

We introduced a new approach for perfusing the liver in ERAT using transhepatic-intrahepatic branches of the PV catheterization. Afterward, ERAT was successfully performed.

OUTCOMES

For patient 1, the WIT was 2 minutes and the cold ischemia time (CIT) was 296 minutes. For patient 2, the WIT was 2 minutes and the CIT was 374 minutes. Patient 1 suffered stenosis of the common bile duct on postoperative day 14, and patient 2 recovered uneventfully. Both of the 2 patients were discharged from the hospital with normal laboratory values on postoperative day 31 and 15, respectively. The laboratory values for both patients at recent follow-up were normal.

LESSONS

Transhepatic-intrahepatic branches of the PV catheterization is useful for decreasing WIT and facilitating the management of ERAT. It is a useful technical variant that could be used in ERAT for treating patients with severe portal hepatis invasion.

Machine perfusion for liver transplantation in the era of marginal organs-New kids on the block

In the face of a critical organ shortage in the Western world, various strategies are employed to expand the donor pool for orthotopic liver transplantation (OLT). Among them is the transplantation of organs from extended criteria donors, a valuable source of liver allografts, however, characterized by potential risks for post-OLT complications and inferior outcomes. In recent years, machine perfusion (MP) of the explanted donor liver as well as regional perfusion techniques has witnessed significant advancements. Here, we aim to discuss different modes of dynamic organ preservation in OLT. These include hypothermic and normothermic MP, hypothermic oxygenated machine perfusion (HOPE), controlled oxygenated rewarming as well as regional perfusion protocols. Over recent years, multiple feasibility trials have demonstrated the clinical prospects of MP. In the context of OLT using organs from extended criteria donors, MP has numerous advantages compared to conventional cold storage, some of which include the preservation and reconditioning of borderline transplantable organs and the viability assessment of high-risk donor allografts. This review aims to address the topic of liver allograft MP, highlighting particularly the current trends in clinical applications and future perspectives. Furthermore, different approaches of liver storage and reconditioning are reviewed in the context of ongoing research.

Subcutaneous Inoculation of Echinococcus multilocularis Induces Delayed Regeneration after Partial Hepatectomy

Alveolar echinococcosis (AE) is caused by the larval stage of echinococcus multilocularis (E. multilocularis), and hepatectomy is the main modality in hepatic AE patients. Liver regeneration after partial hepatectomy (PHx) in such patients is challenging, and further investigation is needed. Thus far, knowledge regarding the possible impact of E. multilocularis on liver regeneration after PHx is limited. Herein, a subcutaneous infection model of E. multilocularis was developed in C57 BL/6 mice, and after 3 months, PHx was performed. Plasma and liver samples were harvested under inhalational isofluorane (2%) anaesthesia at designated post-PHx time points (0, 24, 48, 96 and 168 h). The parameters included the future remnant liver/body weight ratio (FLR/BW), liver function tests (AST and ALT) and related cytokines (TNF-α, IL-6, Factor V, HMGB1, TGF-β, TSP-1, and TLR4) and proteins (MyD88 and STAT3). To assess the proliferation intensity of hepatocytes, BrdU, Ki67 and PAS staining were carried out in regenerated liver tissue. The FLR/BW in the infected group from 48 h after surgery was lower than that in the control group. The BrdU positive hepatocyte proportions reached their peak at 48 h in the control group and 96 h in the infected group and then gradually decreased. During the first 48 h after surgery, both the AST and ALT levels in the infected group were lower; however, these levels were altered from 96 h after surgery. In the infected group, the concentrations and mRNA expression levels of the pre-inflammatory cytokines TNF-α and IL-6 demonstrated a delayed peak. Moreover, post-operatively, the TGF-β and TSP-1 levels showed high levels in the infected group at each different time-point compared to those in the control group; however, high levels of TGF-β were observed at 96 h in the control group. The MyD88 and STAT3 protein expression levels in the infected group were markedly higher than those in the control group 96 h after surgery. Delayed liver regeneration after PHx was observed in the C57 BL/6 mice with the subcutaneous infection of E. multilocularis in the current study. This phenomenon could be partially explained by the alteration in the pro-inflammatory cytokines in the immunotolerant milieu induced by chronic E. multilocularis infection.

Vascular infiltration-based surgical planning in treating end-stage hepatic alveolar echinococcosis with ex vivo liver resection and autotransplantation

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.

Ex vivo liver resection and autotransplantation as alternative to allotransplantation for end-stage hepatic alveolar echinococcosis

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.

Novel techniques and preliminary results of ex vivo liver resection and autotransplantation for end-stage hepatic alveolar echinococcosis: A study of 31 cases

Ex vivo liver resection combined with autotransplantation is a recently introduced approach to cure end-stage hepatic alveolar echinococcosis (HAE), which is considered unresectable by conventional radical resection due to echinococcal dissemination into the crucial intrahepatic conduits and adjacent structures. This article aims discuss the manipulation details and propose reasonable indications for this promising technique. All patients successfully underwent liver autotransplantation with no intraoperative mortality. The median weight of the autografts was 636 g (360-1300 g), the median operation time was 12.5 hours (9.4-19.5 hours), and the median anhepatic phase was 309 minutes (180- 460 minutes). Intraoperative blood loss averaged 1800 mL (1200-6000 mL). Postoperative complications occurred in 13 patients during hospitalization; 5 patients experienced postoperative complications classified as Clavien-Dindo grade III or higher, and 2 patients died of intraabdominal bleeding and acute cerebral hemorrhage, respectively. Twenty-nine patients were followed for a median of 14.0 months (3-42 months), and no HAE recurrence was detected. The technique requires neither an organ donor nor any postoperative immunosuppressant, and the success of the treatment relies on meticulous preoperative assessments and precise surgical manipulation.

Plasma IL-23 and IL-5 as surrogate markers of lesion metabolic activity in patients with hepatic alveolar echinococcosis

Fluorodeoxyglucose (FDG) uptake by alveolar echinococcosis (AE) liver lesions is a signal of their metabolic activity and of disease progression. In order to find a surrogate marker for this status, we investigated whether parameters of the peripheral and/or periparasitic immune responses were associated with metabolic activity in a prospective case-control study of 30 AE patients and 22 healthy controls. Levels of 18 cytokines and chemokines, representative of innate and adaptive immune responses, were assessed in plasma and peripheral cells of two groups of patients with (MAAE) and without (MIAE) metabolically active lesions, and in the liver of MAAE patients. Mixed cytokine profile was observed in the peripheral blood of AE patients, with a predominance of Th2, Th17 and Treg responses. Among the detected markers only plasma IL-5 and IL-23, more elevated in MAAE patients, were found discriminant. Discrimination between MAAE and MIAE patients obtained by using IL-23 was improved when IL-5 was used in combination. The combination of elevated levels of IL-5 and IL-23 is significantly associated with FDG uptake at PET scan. It offers a new tool for the follow-up of AE patients which could substitute to FDG-PET whenever non-available to assess disease progression.