Vena cava encirclement predicts difficult native hepatectomy

Abstract

Recipient hepatectomy is a challenging liver transplantation (LT) procedure that has life-threatening complications. The current predictive mortality clinic-biological scores (Child/Model for End-Stage Liver Disease [MELD]) do not take into consideration the recipient's liver anatomy. The aim of this study was to evaluate the impact of the dorsal sector anatomy of a cirrhotic liver on the morbidity/mortality rates of hepatectomy. A multicenter retrospective study (clinic-biological and morphologic) was performed from 2013 to 2014. The degree of encirclement of the inferior vena cava (IVC) by the dorsal sector of the liver was measured. The study population included 320 patients. Seventyfour (23%) patients had complete IVC encirclement. A correlation (P 5 0.01) has been reported between the existence of a circular dorsal sector and the number of transfusions during LT (4 packed red blood cell [PRBC] transfusions in the group without IVC versus 7 PRBC transfusions in the other group). The existence of such anatomy increases the relative risk of early reoperation for IVC bleeding by 31% (P 5 0.05). There is a correlation between alcoholic cirrhosis and dorsal-sector hypertrophy (126 cc versus 147.5 cc; P 5 0.05). Concerning surgical time, we found no significant between-group differences. Compared to the severity of cirrhosis, an inverse correlation was observed between the MELD and Child scores and the dorsal sector hypertrophy (P < 0.001). No significant difference in terms of transfusion was found between the temporary portocaval shunt group (n 5 168) and the other group (n 5 152). The presence of a circular sector is associated with an increased risk of hemorrhage during hepatectomy, as well as an immediate postoperative risk of reoperation.Liver Transplantation 22 906-913, 2016 AASLD. The first step in liver transplantation (LT) consists of a full hepatectomy. Initial LT techniques are required to replace the recipient's inferior vena cava (IVC) at the retrohepatic part. (1) Reconstruction techniques allowing for the preservation of the IVC have been described. (2) The hepatectomy represents the most difficult time during surgery, with life-threatening complications related to the risk of massive hemorrhage. In addition, the difficulty of hepatectomy is hard to define and to anticipate. There is no preoperative score that considers the morphological data of the native liver to anticipate hepatectomy difficulty; the existence of hypertrophy in the dorsal sector has been quoted by many authors, but there are few analyses of the surgical impact. The difficulty of hepatectomy seems to be related to the release of the IVC, and, thus, it depends on the hepatic segment in contact with the vein: the involved segments are segment I (S1) and segment IX (S9), according to Couinaud, (3) and anatomical variations of this hepatic sector are important.

Temporary Portocaval Shunt Provides Superior Intra-operative Hemodynamics and Reduces Blood Loss and Duration of Surgery in Live Donor Liver Transplantation

“…It also improves operative exposure during retrocaval dissection, especially in those with a large circular caudate, leading to fewer IVC injuries in the TPCS group than in the non-TPCS group. Panaro et al 15 have also exhibited an increased risk of bleeding and requirement for PRBCs in patients with a large circular dorsal sector. In the current RCT, 43% of recipients had > 180 degrees caudate wrap around the IVC, with 7 patients having near-complete IVC wrap, and IVC injuries during recipient hepatectomy occurred eight times more in the no TPCS group.…”

“…Serum endotoxin levels were measured 12 hours before and 12 hours after surgery and categorized as positive ≥20 pg/mL, negative <10 pg/mL, and indeterminate 10 to 20 pg/mL (done by chemiluminescence assay kit). The caudate wrap was assessed by the degree of IVC encirclement by the dorsal sector hepatic parenchyma, measured on contrast-enhanced computed tomography (CT) images, and categorized into <180 degrees, 180 degrees to 270 degrees and 270 degrees to 360 degrees 15 …”

“…The caudate wrap was assessed by the degree of IVC encirclement by the dorsal sector hepatic parenchyma, measured on contrast-enhanced computed tomography (CT) images, and categorized into <180 degrees, 180 degrees to 270 degrees and 270 degrees to 360 degrees. 15…”

Subjective Difficulty Scale in Liver Transplantation: A Prospective Observational Study

“…Adhesions, sometimes filled by portal hypertension, and modified anatomical landmark makes ReLT more challenging than primary transplantation ( 23 , 24 ). A complete encirclement of the retrohepatic inferior vena cava is known to increase the difficulty and the risk of total hepatectomy with caval preservation ( 25 ). Preexisting TIPS is also associated with an increased risk of bleeding during total hepatectomy, especially in cases of misplacement ( 26 ).…”

Upper Midline Incision in Recipients of Deceased-Donors Liver Transplantation

“…Thus, it is believed that the need for enlargement of the incision is to provide better surgical field in these areas. The safety and effectiveness of the midline incision in hepatic resections has been demonstrated for almost a decade 4 , 21 , 22 , 24 . A bleeding reoperation occurred in retrocaval space on the 2 nd postoperative day, without the need to modify the incision, and there were no significant repercussions in the graft or in the patient.…”