Ex-vivo resection techniques in tissue-preserving surgery for liver malignancies

Abstract

Some primary and secondary liver tumours are not absolutely irresectable, but cannot be resected using a conventional approach because of the limited warm ischaemia tolerance of the liver or poor accessibility of the tumour region. In such situations, the techniques of ex vivo liver surgery, pioneered by Rudolf Pichlmayr some 10 years ago, offer new chances for R0 resection. All the three different approaches, namely "in situ"-, "ante situm"-, and "ex situ" resection, require the use of measures originally developed for transplantation, such as hypothermic liver perfusion and veno-venous bypass. They differ mainly in the extent to which major vessels are divided in order to achieve optimal mobility of the organ. The results show that radical resection can be achieved accomplished in many cases. If necessary, complex vascular reconstructions can be performed. Although perioperative morbidity and mortality are high, there are a number of long-term survivors. Tumour recurrence, however, remains the main problem over the long term. In conclusion, ex vivo liver surgery is an important extension of surgical treatment possibilities. However, the procedure is suitable only for a small number of carefully selected patients and should be reserved for use in specialised centres. Furthermore, in view of the fact that the results are not yet optimal, additive and adjuvant treatment modalities are needed.

Ex vivo hepatectomy and partial liver autotransplantation for hepatoid adenocarcinoma: A case report

“…This technique may be the last resource for otherwise unresectable malignancy (14), but the associated morbidity and mortality remain high, and tumor recurrence is a major problem. Raab et al (21) also recommended that the ex situ procedure be used only in specialized centers with extensive experience in both conventional liver surgery and transplantation.…”

Current status of the organ replacement approach for malignancies and an overture for organ bioengineering and regenerative medicine

“…Application of transplantation techniques in cancer surgery Autotransplantation Ex vivo tumor resection and organ reimplantation (autotransplantation) for extensive hepatic and gastrointestinal malignancies involving mesenteric and/or celiac root deemed unresectable by conventional surgery is an offspring of solid organ transplantation. It has now evolved from single organ [128][129][130][131][132][133][134][135] to multivisceral surgery. 136,137 The major advantages of this approach are excellent exposure enabling complete tumor eradication in a bloodless field at the back table and eliminating the use of immunosuppression.…”

“…129 Since then, liver tumors involving the confluence of hepatic veins and/or the retrohepatic vena cava were resected by this approach in more than 50 patients and every report underscores the paramount importance of deliberate patient selection. 130,134,[138][139][140][141][142] Ciancio et al depicted the use of the mobilization technique in LT for resection of renal cell carcinoma with tumor thrombus in the inferior vena cava 143 and en bloc mobilization of the pancreas and spleen, which was derived from multivisceral transplantation as well as organ procurement, for resection of large tumors in the left upper abdomen. 144 Both procedures were successfully performed with minimum risk while maximizing the chance of complete resection.…”

Strategies to Increase the Resectability of Liver Metastases from Colorectal Cancer

“…This applies mainly to patients with CLM at the hepatocaval confluence or with extensive infiltration of the IVC. In these situations, the techniques of ex vivo liver surgery, pioneered by Pichlmayr et al [115]more than 10 years ago, have offered the possibility to perform radical resections [108, 116, 117, 118]. The three techniques described can be categorized as in situ, ante situm and ex situ resection.…”

“…These techniques are associated with far greater morbidity and mortality than conventional liver resection [116]. The development of irreversible liver failure after ex situ liver surgery can cause a serious ethical dilemma, as the only chance for survival might rely on liver transplantation [118].…”