Ex vivo liver resection coupled with associated liver partition and portal vein ligation: Combining existing techniques to achieve surgical resectability

Abstract

Incorporation of liver transplant techniques in hepatopancreaticobiliary surgery has created an opportunity for the resection of locally advanced hepatic tumors formerly considered unresectable. A 73‐year‐old woman presented with cholangiocarcinoma involving inferior vena cava, all three hepatic veins, and right anterior portal pedicle, initially deemed nonoperative. This case demonstrates the first combined application of associating liver partition and portal vein ligation for staged hepatectomy and ex vivo resection to perform an R0. For diseases dependent upon resection, surgical advances and innovations expand the spectrum of interventions through interdisciplinary techniques.

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

“…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. 1,21,36,40 Operative planning is likely to be helpful in determining the most suitable resection planes and avoiding complications. The RLV should be assessed quantitatively and qualitatively prior to operation as well as before the back bench resection phase to avoid small-for-size liver syndrome and to ensure postoperative maintenance of normal liver function.…”

“…22 There were 6 patients (2.6%) in whom some procedure aimed to increase their future liver remnant was performed, involving either portal vein embolization 21,23 or associating liver partition and portal vein ligation for staged hepatectomy. 1,8 Most patients had normal liver function and no history of cirrhosis. All patients' details and characteristics are presented in Tables I and II.…”

“…Resection is the best method to treat the vast majority of those conditions and to provide long-term survival. 1 Unfortunately, not all patients are eligible for resection by conventional techniques, even after portal vein embolization or with the use of the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS procedure). This applies mainly to those with poor liver function and with lesions in difficult anatomic sites, especially with the involvement of large blood vessels.…”

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“…In order to maximize the benefits of various techniques of liver surgery and to achieve the resectability of tumoral lesions, certain authors proposed the combination of ex vivo liver resection with other pre-existing techniques such as liver partition and portal vein ligation with encouraging results. therefore, Baimas-george et al recently reported the case of a 73-year-old patient diagnosed with a large cholangiocarcinoma invading the inferior cava vein, the three hepatic veins and the right anterior portal pedicle in whom liver partition and portal vein ligation followed by ex vivo resection of the remnant liver tumor was performed, an r0 resection being achieved (16).…”

The Janus of mIS in hepatobiliary surgery: Importance of maximally invasive surgery in an era of minimally invasive surgery

“…Our institution has performed seven hypothermic IVC resections when conventional techniques have been inadequate, altering the definition of resectability, making it oncologic rather than technical. For instance, when a patient was diagnosed with cholangiocarcinoma involving IVC and all three hepatic veins, conventionally far from resectable, the first combined application of ALPPS with an ex-vivo liver resection, after neoadjuvant chemotherapy, led to a successful R0 resection and a survival of 27 months at last follow-up [11] .…”