Retrocaval liver lifting maneuver and modifications of total hepatic vascular exclusion for liver tumor resection

Surgical approach to achieve R0 resections in primary and metastatic liver tumors: a literature review

Background and Objective

Primary and metastatic liver tumors are a significant cause of mortality worldwide. Regardless of the etiology of the tumor, macro- and microscopically clear margins (R0) while preserving adequate function of the remaining organ are the main goals after liver resections. However, technically challenging procedures are required to achieve R0 resection. Currently, there is no consensus of which should be the ideal minimal safety margin for liver tumor resections, with contrasting reports in regards of safety, tumor recurrence and overall outcomes following R0. Therefore, we aim to review current worldwide surgical practices to achieve R0 resections for primary and metastatic liver tumors in challenging surgical techniques and their reported outcomes.

Methods

PubMed database, Google Scholar, and OVID Medline were searched for peer-reviewed original articles related to surgical techniques performed to achieve R0 resections in the setting of primary and/or metastatic liver tumors. An up-to-date review of English-language articles published between 2015 to July 2022 was performed.

Key Content and Findings

Primary and metastatic liver tumors can be effectively treated using hepatic resection. Current literature highlights that tumors involving major vascular structures are not uncommon. Surgical advances have allowed for vascular control techniques, as well as vascular resections to be performed in a feasible and safe manner to achieve R0 resections. Complex resections combining surgical techniques can be performed in certain population after a detailed evaluation. Liver transplantation (LT) have been used with varying degrees of success for treatment of patients with hepatocellular carcinoma, cholangiocarcinoma (CCA), colorectal liver metastases (CRLM), non-resectable CRLM and metastatic neuroendocrine tumors.

Conclusions

Safety and feasibility of R0 resections have been reported for multiple techniques. Technical complexity should not be a limitation to achieve or pursue R0 tumor resection. However, there has to be a balance between patient risk/benefit in attempting R0 resections. Adequate training of surgeons on implementation of complex techniques, as well as transplant oncology techniques applied to hepato-pancreato-biliary (HPB) surgery represents as a promising path to improve short and long-term outcomes for liver-related oncology patients.

Patch venoplasty for resecting tumor invading the retrohepatic inferior vena cava using total and selective hepatic vascular exclusion

Large hepatic tumors can invade the retrohepatic inferior vena cava (IVC). Resecting the involved IVC wall is necessary to achieve complete tumor resection. We present detailed surgical procedures of IVC resection and patch venoplasty under the standard and modified total hepatic vascular exclusion (THVE) techniques applied to two patients who underwent aggressive surgery for hepatic tumors. The first case was a 55-year-old male with advanced intrahepatic cholangiocarcinoma. The extent of resection was extended right hepatectomy with caudate lobe resection, right adrenalectomy, and portal vein segmental resection-anastomosis. The invasion site at the IVC was excised and repaired with an expanded polytetrafluoroethylene patch under modified THVE. This patient recovered uneventfully. At postoperative 10 months, second primary cancer occurred in the duodenum. The patient underwent pancreaticoduodenectomy but passed away at post-surgery 6 weeks due to pneumonia-associated sepsis. The second case was a 35-year-old female with giant cavernous hemangioma. As separating the right liver from the IVC was infeasible through conventional dissection techniques, standard THVE was performed. The short hepatic vein was too large to repair directly without risk of IVC stenosis. Thus, a cryopreserve iliac vein allograft patch was applied to repair the defect. The patient recovered uneventfully from the operation. The patient is currently doing well for 6 years. However, progressive hemangiomatosis occurred. In conclusion, standard and modified THVE techniques are proposed as useful techniques to achieve complete tumor resection in patients with large liver tumors invading the retrohepatic IVC.

Vascular Involvements in Cholangiocarcinoma: Tips and Tricks

Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract. To date, surgical treatment remains the only hope for definitive cure of CCA patients. Involvement of major vascular structures was traditionally considered a contraindication for resection. Nowadays, selected cases of CCA with vascular involvement can be successfully approached. Intrahepatic CCA often involves the major hepatic veins or the inferior vena cava and might necessitate complete vascular exclusion, in situ hypothermic perfusion, ex situ surgery and reconstruction with autologous, heterologous or synthetic grafts. Hilar CCA more frequently involves the portal vein and hepatic artery. Resection and reconstruction of the portal vein is now considered a relatively safe and beneficial technique, and it is accepted as a standard option either with direct anastomosis or jump grafts. However, hepatic artery resection remains controversial; despite accumulating positive reports, the procedure remains technically challenging with increased rates of morbidity. When arterial reconstruction is not possible, arterio-portal shunting may offer salvage, while sometimes an efficient collateral system could bypass the need for arterial reconstructions. Keys to achieve success are represented by accurate selection of patients in high-volume referral centres, adequate technical skills and eclectic knowledge of the various possibilities for vascular reconstruction.

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.

Treatment of hepatocellular carcinoma with hepatic vein tumor thrombosis protruding into the inferior vena cava by conversion surgery following chemotherapy with regorafenib: a case report

Regorafenib is an oral multikinase inhibitor affecting angiogenesis, oncogenesis, metastasis, and tumor immunity. As a systemic treatment, it has been shown to provide survival benefits in hepatocellular carcinoma (HCC) patients progressing on sorafenib treatment. We report herein a case of HCC with hepatic vein tumor thrombosis protruding into the inferior vena cava (IVC-HVTT) which was successfully treated by surgery following second-line chemotherapy with regorafenib. A 79-year-old man with chronic hepatitis was diagnosed with HCC. Computed tomography revealed a solitary tumor in segments 7 and 8 and an IVC-HVTT from the right hepatic vein. Since IVC-HVTT removal is a difficult procedure, the tumor was diagnosed as unresectable, and administration of sorafenib was started. Five weeks later, the lesion had increased in size by 15.3%; subsequently, regorafenib was given as second-line therapy for 12 months. After shrinkage of the IVC-HVTT, the patient was referred to our hospital for surgery. One month after the cessation of regorafenib, an extended resection of segment 8 and total removal of the IVC-HVTT was successfully performed without using total hepatic vascular exclusion. There were no serious postoperative complications. Additionally, there has been no recurrence for about 2 years since the initial therapy.

Usefulness of Infra-hepatic Inferior Vena Cava Clamping During Liver Resection: a Meta-analysis of Randomized Controlled Trials

BACKGROUND

Infra-hepatic vena cava clamping (IIVCC) may reduce blood losses during liver resection. However, available literature is limited to reports from single institutions with a small sample size. To overcome those limitations, we performed a meta-analysis to examine the association between IIVCC and surgical outcomes.

METHODS

A systematic literature review was conducted to identify RCTs reporting on quantitative data on IIVCC. Random effects logistic regression calculated the pooled odds ratio (OR) for each surgical outcome.

RESULTS

Six studies were identified that included 714 patients, of whom 359 received IIVCC and 355 did not. Patients receiving IIVCC had significantly less total blood loss (MD - 353.08, 95% CI - 393.36 to 312.81, P < 0.00001), blood loss during parenchymal transection (MD - 243.28, 95% CI - 311.67 to - 174.88, P < 0.0001), blood loss volume per transection area (MD - 1.63, 95% CI - 2.14 to - 1.13, P < 0.00001), and intraoperative blood transfusion (OR 0.45, 95% CI 0.23 to 0.89, P = 0.02). Operative time was similar in the two groups (MD - 2.89, 95% CI - 18.45 to 12.68, P = 0.72). No differences between groups were observed in central venous pressure, heart rate, and mean arterial pressure before, after, and during parenchymal transection. Rates of overall morbidity (OR 0.79, 95% CI 0.56-1.13, P = 0.20), major complications (OR 0.89, 95% CI 0.47-1.80, P = 0.73), and perioperative mortality (OR 1.32, 95% CI 0.29-6.09, P = 0.72) were similar in the two groups.

CONCLUSIONS

IIVCC was associated to decreased blood loss (overall, during parenchymal transection, and per transection area) and decreased intraoperative transfusions, in the absence of increased operative times.