Ex Vivo and In Situ Resection of Inferior Vena Cava With Hepatectomy for Colorectal Metastases

Lodge, J. Peter A.; Ammori, Basil J.; Prasad, Kondapalli Siva; Bellamy, Mark

doi:10.1097/00000658-200004000-00004

Cited by 152 publications

(131 citation statements)

References 37 publications

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“…This aggressive surgical approach offers hope for patients with hepatic tumors involving the IVC, who would otherwise have a dismal prognosis. This procedure can be performed under total hepatic vascular exclusion, with or without veno-venous bypass, and by ex vivo resection [4] . Control of blood flow through the IVC is essential to facilitate resection and reconstruction.…”

Section: Discussionmentioning

confidence: 99%

Resection and reconstruction of the inferior vena cava for neoplasms

Vladov¹,

Mihaylov²,

Belev³

et al. 2012

WJGS

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AIM:To evaluate the results of an aggressive surgical approach of resection and reconstruction of the inferior vena cava (IVC). METHODS:The approach to caval resection depends on the extent and location of tumor involvement. The supra-and infra-hepatic portion of the IVC was dissected and taped. Left and right renal veins were also taped to control the bleeding. In 12 of the cases with partial tangential resection of the IVC, the flow was reduced to less than 40% so that the vein was primarily closed with a running suture. In 3 of the cases, the lumen of the vein was significantly reduced, requiring the use of a polytetrafluoroethylene (PTFE) patch. In 2 of the cases with segmental resection of the IVC, a PTFE prosthesis was used and in 1 case, the IVC was resected without reconstruction due to shunting the blood through the azygos and hemiazygos veins. RESULTS:The mean operation time was 266 min (230-310 min) with an average intraoperative blood loss of 300 mL (200-2000 mL). The patients stayed in intensive care unit for 1.8 d (1-3 d). Mean hospital stay was 9 d (7-15 d). Twelve patients (66.7%) had no complications and 6 patients (33.3%) had the following complications: acute bleeding in 2 patients; bile leak in 2 patients; intra abdominal abscess in 1 patient; pulmonary embolism in 2 patients; and partial thrombosis of the patch in 1 patient. General complications such as pneumonia, pleural effusion and cardiac arrest were observed in the same group of patients. In all but 1 case, the complications were transient and successfully controlled. The mortality rate was 11.1% (n = 2). One patient died due to cardiac arrest and pulmonary embolism in the operation room and the second one died 2 d after surgery due to coagulopathy. With a median follow-up of 24 mo, 5 (27.8%) patients died of tumor recurrence and 11 (61.1%) are still alive, but three of them have a recurrence on computed tomography. CONCLUSION:There are a variety of options for reconstruction after resection of the IVC that offers a higher resectable rate and better prognosis in selected cases.

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Section: Discussionmentioning

confidence: 99%

Resection and reconstruction of the inferior vena cava for neoplasms

Vladov¹,

Mihaylov²,

Belev³

et al. 2012

WJGS

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“…They mobilized the liver from the body after the division of the hepatic veins, retaining the connection of the hepatic pedicle, and resected 3 huge liver tumors, including a diffuse hemangioma. Complete ex situ ECHR was reported by Pichlmayr et al 2 in 1990 with a success rate of 4/9 (44.4%), and this was followed by Yanaga et al 3 from our center in 1993 and Lodge et al 4 in 2000. Although not in the English literature, Brekke et al 5 and Severtsev 6 both reported ECHR and autotransplantation similar to the current case.…”

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confidence: 57%

“…[1][2][3][4][5][6][7] The benefit of liver transplantation is its simple surgical concept, and the benefits of ECHR are that it is immunosuppression-free and that organ donors are unnecessary. [1][2][3][4][5][6] The patient was a 39-year-old female referred to our hospital for possible living donor liver transplantation for her huge and multiple unresectable hemangiomas of the liver. Although she had undergone transcatheter arterial embolization 6 months previously, they showed an increase in size.…”

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confidence: 99%

Extracorporeal hepatic resection for unresectable giant hepatic hemangiomas

et al. 2007

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In order to perform surgical treatment for tumors unresectable for anatomical reasons, there are two approaches: one is liver transplantation, and the other is extracorporeal hepatic resection (ECHR). [1][2][3][4][5][6][7] The benefit of liver transplantation is its simple surgical concept, and the benefits of ECHR are that it is immunosuppression-free and that organ donors are unnecessary. [1][2][3][4][5][6] The patient was a 39-year-old female referred to our hospital for possible living donor liver transplantation for her huge and multiple unresectable hemangiomas of the liver. Although she had undergone transcatheter arterial embolization 6 months previously, they showed an increase in size. At the time of referral, she demonstrated abdominal distention with shortness of breath. Her laboratory testing showed normal liver function tests, including a total bilirubin level of 1.3 mg/dL, an albumin level of 4.3 g/dL, and a prothrombin time of 13.6 seconds. A computed tomography scan of the abdomen showed 4 huge tumors (Fig. 1). This location of the tumors and their benign origin led us to choose ECHR rather than living donor liver transplantation after detailed informed consent was obtained. As is well known, the chance of receiving a liver graft from a deceased donor is almost zero in Japan. [7][8][9] The estimated autograft volume after ECHR was 590 g, representing a graft volume/standard liver volume ratio of 49.6% (Fig. 2).The patient was taken to the operating room, and laparotomy was performed (Fig. 3). The liver was severely enlarged, but the nontumor portion looked like normal hepatic parenchyma. After the dissection of the hilar structures at the mid-hilum, the portosystemic venovenous bypass, using reinforced venous cannulas (Edwards Life Sciences, Inc., Irvine, CA), was established from the inferior mesenteric vein with 16Fr and from the left saphenous vein with 15Fr to the left axillary vein with 14Fr. The patient was started on the bypass at the rate of 4 L/min with a stable circulatory condition. After the division of the proper hepatic artery, the total liver was mobilized from the diaphragm. The common hepatic duct was divided, the vascular clamps were applied and followed by division on the portal vein and suprahepatic and infrahepatic vena cava, and then the total hepatectomy was performed. The explanted liver was flushed with 3 L of normal saline followed by 3 L of University of Wisconsin solution. Intraoperative ultrasound was done on the backtable for the determination of the exact cutting line. After dissection of the vena cava from the dorsal liver with ligation of the short hepatic veins, the huge hemangiomas in segment 1, segment 2 to 3, caudal segment 4, and segment 6 to 7 were resected with a Cavitron ultrasonic surgical aspirator (Valleylab, Inc., Boulder, CO; Fig. 2). After resection, vascular and biliary leakage tests using an injection of University of Wisconsin solution were performed, and the leakage points were repaired with fine sutures. The actual weight of the whole explanted...

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“…While the mean durations of THVE were 29 min to 78 min in the reports from very experienced institutes [1,2,7,8] , the mean THVE duration in the present study was only 13.4 ± 8.4 min. The mortality rates of hepatectomy with IVC resection were 4.5% to 25% in the previous reports [1][2][3][4]8,10,11,15] . In particular, the morbidity and mortality rates were quite high when standard THVE was applied frequently, even when hypothermic perfusion was used to attenuate the ischemic liver damage.…”

Section: Discussionmentioning

confidence: 99%

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

Ko¹,

Kirihataya²,

Yayoi³

et al. 2016

WJH

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AIM:To evaluate the efficacy of technical modifications of total hepatic vascular exclusion (THVE) for hepatectomy involving inferior vena cava (IVC). METHODS:Of 301 patients who underwent hepatectomy during the immediate previous 5-year period, 8 (2.7%) required THVE or modified methods of IVC cross-clamping for resection of liver tumors with massive involvement of the IVC. Seven of the patients had diagnosis of colorectal liver metastases and 1 had diagnosis of hepatocellular carcinoma. All tumors involved the IVC, and THVE was unavoidable for combined resection of the IVC in all 8 of the patients. Technical modifications of THVE were applied to minimize the extent and duration of vascular occlusion, thereby reducing the risk of damage. RESULTS:Broad dissection of the space behind the IVC coupled with lifting up of the liver from the retrocaval space was effective for controlling bleeding around the IVC before and during THVE. The procedures facilitate modification of the positioning of the cranial IVC cross-clamp. Switching the cranial IVC cross-clamp from supra-to retrohepatic IVC or to the confluence of hepatic vein decreased duration of the THVE while restoring hepatic blood flow or systemic circulation via the IVC. Oblique cranial IVC cross-clamping avoided ischemia of the remnant hemi-liver. With these technical Retrocaval liver lifting maneuver and modifications of total hepatic vascular exclusion for liver tumor resection Retrospective Study ORIGINAL ARTICLEmodifications, the mean duration of THVE was 13.4 ± 8.4 min, which was extremely shorter than that previously reported in the literature. Recovery of liver function was smooth and uneventful for all 8 patients. There was no case of mortality, re-operation, or severe complication (i.e. , Clavien-Dindo grade of Ⅲ or more). CONCLUSION:The retrocaval liver lifting maneuver and modifications of cranial cross-clamping were useful for minimizing duration of THVE.

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Ex Vivo and In Situ Resection of Inferior Vena Cava With Hepatectomy for Colorectal Metastases

Abstract: ObjectiveTo describe the surgical techniques and early results of inferior vena cava (IVC) resection in patients with advanced liver tumors.

Cited by 152 publications

References 37 publications

Resection and reconstruction of the inferior vena cava for neoplasms

Resection and reconstruction of the inferior vena cava for neoplasms

Extracorporeal hepatic resection for unresectable giant hepatic hemangiomas

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

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