Ex situ Liver Resection for Unresectable Tumors

Abstract

Primary and secondary liver tumors are among the most common tumors in humans. Two surgical approaches may be used to address these tumors: liver transplantation and liver resection. However, some tumors cannot be treated by conventional techniques or liver transplantation due to poor intraoperative exposure, limitations of indication standards, and/or other complex factors. To overcome these problems, ex situ liver resection has been introduced and used successfully in many cases. This technique is based primarily on liver transplantation and perfusion with preservation solution under hypothermic conditions. The major indications for ex situ liver resection are liver tumors that are unresectable or in which resection using conventional surgical techniques is very dangerous due to the close proximity to or involvement of the venous confluence and/or the main hepatic veins. However, high mortality and morbidity rates limit the use of this technique despite the efforts of many surgeons to improve their skills. Patient selection is of utmost importance to achieve a good outcome. Emphasis on basic research (e.g. on reperfusion injury) and the development of key techniques should improve the safety of the procedure and reduce mortality in the future.

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

“…Mortality is mainly attributed to factors like liver failure and sepsis [5]. The most common complications after ex situ liver resection other than sepsis and liver failure include bleeding and biliary leakage [10]. Among patients who have the procedure for tumors, during long term, the biggest issue remains to be recurrence of the primary tumor [11].…”

Ex situ liver resection and autotransplantation for advanced cholangiocarcinoma

“…In a large volume transplant centre, complex vascular reconstructions are feasible and allow for more radical surgery than was previously thought possible. However, associated high morbidity with this complex surgery makes appropriate patient selection as important as the technical expertise required for the procedure 3 8. When properly selected, a small but significant subset of patients with liver tumour can benefit with this demanding procedure, offering the only hope of a survival benefit and potential cure.…”

Ante-situm Liver Resection for Giant Hepatic Tumour - Case Report and Review of Literature

“…The total liver volume (TLV) and future remnant liver volume (FRLV) were measured using OsiriX®, a free software offered by the Swiss company Pixmeo SARL (4). A TLV of 3034 cm 3 was calculated, compound of 1446 cm 3 of FRLV (47.65%) and 1597 (52,35 %) cm 3 tumour volume (Fig. 2).…”

“…Ex-situ liver surgery refers to complex liver resections involving hepatic vascular exclusion and a warm ischemia time (WIT) of more than 90 minutes that allows liver resection and vascular reconstruction in patients with giant liver tumours with a difficult approach [in close proximity of the inferior vena cava (IVC)], or tumours involving the vena cava or suprahepatic veins considered to be unresectable by conventional surgery techniques (1). The antesitum, also called "ex situ -in vivo" liver resection, is achieved through externalization of the liver outside of the abdominal cavity by clamping and sectioning of the efferent pedicles (suprahepatic veins) ("ex situ") without cutting the afferent vascular pedicle ("in vivo"), thus leaving the hepatic pedicle intact (2,3).…”