Ex situ liver resection and autotransplantation for advanced cholangiocarcinoma

Abstract

Advanced cholangiocarcinoma especially those involving the vasculature have extremely limited options of cure. Ex situ liver resection entails performing a total hepatectomy, resecting the tumour on the back-table followed by reimplantation (autotransplantation) of the liver. Application of this technique for these tumours has rarely been done due to complexity of the procedure and the dismal prognosis of the lesions. We present our experience of two cases of advanced intrahepatic cholangiocarcinoma with limited extrahepatic disease who underwent ex situ resection with autotransplantation. They underwent preoperative therapy with a waiting period to assess the tumour biology. Both patients underwent ex situ resection with extended hepatectomy on the back table. Both patients remain well on follow-up 24 months and 20 months, respectively, with excellent quality of life. Despite its technical complexity, ex situ liver resection may offer prolonged overall survival in selected patients with advanced cholangiocarcinoma and limited extrahepatic disease.

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

“…40,41 ERAT may be most appropriate for tumors of large size and/or difficult anatomic locations, including a severe compression against or infiltration on large vascular or biliary structures (e.g., the retrohepatic IVC, portal structures, hepatic veins, and the hepatocaval confluence). 9,31,35,37,42,43 Furthermore, ERAT is reasonable when previous resections were unsuccessful or when there is a very high operative risk for in situ resections, such as large unstoppable hemorrhage (e.g., in case of hemangioma) or probable liver failure caused by the need for a prolonged operative time with subsequent prolonged warm ischemia injury. 21,22,24,33,42,44 ERAT can only be performed when a sufficient residual liver volume can be ensured after the resection.…”

“…36 Limited extrahepatic metastases might be managed with ERAT as contemporary advancements in chemo-and radiotherapy enable effective treatment of the disease or provide long palliative effect. 43,45 Impaired liver function, as manifested by obstructive jaundice, secondary sclerosing cholangitis, or portal hypertension, and severe damage of the intrahepatic biliary tree make the procedure infeasible. 40 Therefore, these patients should also meet the functional and anatomic criteria to be eligible for ERAT: (1) preoperative expectation of RLV/SLV is at least 35% to 40%; (2) total bilirubin less than twice of the upper limit of normal in patients with obstructive jaundice; and (3) a routine percutaneous transhepatic cholangial drainage must be performed in patients with obstructive jaundice.…”

Ex vivo liver resection for liver tumors: Last resort when conventional technique is not applicable

“…Ex vivo liver resection and autotransplantation (EVLRAT) is feasible but very complex technique.It can apply in few patients with unresectable hepatic tumor fit for surgery, benign tumor or malignant low-grade tumor with long term survival with R0 resection about 60%-90% but outcomes are less satisfactory due to high complications rate of about 25% and low survival in 3 years. EVLRAT may offers a last resort when conventional technique is not applicable (2,4,5,6,7,8,9). In patients with no curative prospect and a life expectancy, this procedure may improve curative surgery and the patient's quality of life (29,30).…”

“…This technique allows the surgeon to have yet another liver resection technique, to be able to access sections of the liver that are difficult to access, to be able to resect the neoplasm better, to operate in a bloodless operating field, to reconstruct the vessels and to avoid a hot ischemia harmful to the liver (4). However, this technique is not used frequently due to the fact that advanced tumors near or involving vascular structures have a poor prognosis, due to the fact that it is an extremely complex technique and, last but not least, that it has a high morbidity and mortality (2,4,5,6,7,8,9). Actually, does not exit an well-stabilish guidelines.The ideal fit patient is the patient suffers of benign tumor or low-grade tumor, huge tumor, tumor near vital structures such as hepatic artery or vena cava or hepatic veins and a patient who can achieves long-term survival.…”

Vascular Involvements in Cholangiocarcinoma: Tips and Tricks

“…When this extreme liver surgery is not feasible, neoadjuvant therapy (NAT) should be considered for two reasons: firstly, NAT can convert as many as 53% of patients with previously unresectable disease to secondary resectable disease [21], and secondly, NAT may serve as a selection process, with progression of patients unlikely to benefit from surgery and those with stable or regressing lesions who are viable candidates for extreme resection [22].…”