Ex vivo resection and temporary portocaval shunt of unresectable hepatocellular carcinoma followed by autotransplantation of liver: a case report

Ex vivo resection, vessel reconstruction and liver autotransplantation for cholangiocarcinoma: A report of two cases

PURPOSE

Ex vivo liver resection and autotransplantation (ERAT) can be used to treat locally advanced tumors that are conventionally unresectable. Because the procedure is rare, there are very few reports in the literature. Recently, we performed ERAT for two cases of cholangiocarcinoma invading caudate lobe, the retrohepatic vena cava and hepatic veins, and investigated technical variations of this procedure.

METHODS

One patient was a 57-year-old man with liver caudate lobe metastasis from cholangiocarcinoma after pancreaticoduodenal resection five years ago, and the other patient was a 68-year-old man with caudate lobe cholangiocarcinoma. Both cases were considered to be unresectable by conventional resection due to the critical invasion of the retrohepatic vena cava along with the three hepatic veins. Therefore, ERAT was indicated in these two cases.

RESULTS

The liver along with the retrohepatic vena cava was removed, which was replaced by GORE-TEX synthetic artificial vessel grafts with angioplasty to reconstruct the inferior vena cava (IVC), and the GORE-TEX synthetic artificial vessel anastomosed to the right auricular appendage or the IVC to build the continuity of the IVC. Ex vivo caudate lobe hepatectomy was performed, along with the retrohepatic vena cava and hepatic veins, and subsequently the reconstruction outflow of hepatic venous was established using cold-preserved allogeneic vessels and falciform ligament. Finally, remnant of the liver was implanted by Piggyback liver transplantation. The hepatic vein, portal vein, hepatic artery and bile duct were anastomosed, and autotransplantation of the liver was completed. The patients were followed-up for 18 months and showed good liver function, with no recurrence of cancer.

CONCLUSIONS

ERAT should be considered as a therapeutic option for selected patients with cholangiocarcinoma invading caudate lobe, the retrohepatic vena cava and hepatic veins. It is crucial to reconstruct the outflow of hepatic venous according to different situations.

Ex vivo liver resection and auto-transplantation as an alternative for the treatment of 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 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.

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.

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.