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Li P, Cheng DH, You XY, Jiang JP, Zuo BY, Yang C, Zhang Y. Combined two-step vascular exclusion and modified in situ hypothermic perfusion for advanced hepatic alveolar echinococcosis with cavernous transformation of portal vein (with video). Hepatobiliary Pancreat Dis Int 2025; 24:206-210. [PMID: 39765370 DOI: 10.1016/j.hbpd.2024.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 12/09/2024] [Indexed: 02/03/2025]
Affiliation(s)
- Peng Li
- Department of Hepatobiliary and Pancreas Surgery, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Dong-Hui Cheng
- Department of Hepatobiliary and Pancreas Surgery, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Xin-Yu You
- Department of Hepatobiliary and Pancreas Surgery, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Ji-Peng Jiang
- Department of Hepatobiliary and Pancreas Surgery, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Bang-You Zuo
- Department of Hepatobiliary and Pancreas Surgery, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Chong Yang
- Department of Hepatobiliary and Pancreas Surgery, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Yu Zhang
- Department of Hepatobiliary and Pancreas Surgery, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China.
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Li L, Hirukawa K, Morinaga J, Goto T, Isono K, Honda M, Sugawara Y, Hibi T. Extreme surgery using the hypothermic perfusion technique for conventionally unresectable abdominal malignant tumours: A systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2025; 51:109692. [PMID: 40010010 DOI: 10.1016/j.ejso.2025.109692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2024] [Revised: 01/26/2025] [Accepted: 02/10/2025] [Indexed: 02/28/2025]
Abstract
BACKGROUND Extreme surgery using the hypothermic perfusion technique is often the only treatment option to achieve R0 resection and long-term prognosis for abdominal tumours that are either conventionally unresectable or contraindicated to allotransplantation. We conducted a systematic review and meta-analysis to delineate the indications and outcomes of extreme surgery. MATERIALS AND METHODS Human studies on extreme resection for abdominal malignant tumours were searched among five databases between January 1988 to March 2023. The Risk Of Bias In Non-randomised Studies - of Interventions tool was used to assess the risk of bias. A meta-analysis of proportions was performed, pooling 1-, 3- and 5-year overall survival and recurrence rates. RESULTS This study comprised 73 studies encompassing 333 patients who underwent extreme liver resection (in situ, n = 127; ante situm, n = 72; ex situ, n = 134). Additionally, 90 patients from 17 studies focusing on extreme resection of other (non-hepatic) organs were included. The pooled 90-day mortality and 1- and 5-year overall survival rates were 7.3 %, 72.3 % and 23.4 %, respectively. The 1- and 5-year recurrence rates were 38.7 % and 86.1 %, respectively. Patients aged <65 years had a significantly lower 90-day mortality (5.5 % vs. 29.6 %; P = 0.022) and a higher 5-year overall survival rate (23.9 % vs. 0 %; P < 0.001) than those aged ≥65 years. Additionally, non-epithelial tumours were associated with favourable prognosis compared with epithelial tumours. CONCLUSION Extreme surgery offers acceptable outcomes for younger patients with non-epithelial tumours that are either unresectable by conventional cancer surgery or contraindicated to allotransplantation.
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Affiliation(s)
- Lianbo Li
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan; Department of Pediatric Surgery, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Sichuan, China
| | - Kazuya Hirukawa
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Jun Morinaga
- Department of Clinical Investigation, Kumamoto University Hospital, Kumamoto, Japan
| | - Toru Goto
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kaori Isono
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Masaki Honda
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Yasuhiko Sugawara
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan.
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Aini A, Lu Q, Wen H, Wang WT, Aji T, Chen ZY, Zhang LD, Yang ZY, Yang JY, Fan HN, Wang WL, Li XC, Zhang Y, Dong JH. Particular Chinese contributions to extracorporeal liver surgery. Hepatobiliary Pancreat Dis Int 2025; 24:57-66. [PMID: 39753427 DOI: 10.1016/j.hbpd.2024.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Accepted: 12/13/2024] [Indexed: 03/17/2025]
Abstract
Extracorporeal liver surgery (ELS), also known as liver autotransplantation, is a hybrid (cross-fertilized) surgery incorporating the technical knowledge from extreme liver and transplant liver surgeries, and recently became more embraced and popularized among leading centers. ELS could be summarized into three major categories, namely, ex-situ liver resection and autotransplantation (ELRA), ante-situm liver resection and autotransplantation (ALRA) and auxiliary partial liver autotransplantation (APLA). The successful development of ELS during the past 37 years is definitely inseparable from continuous efforts done by Chinese surgeons and researchers. Especially, the precision liver surgery paradigm has allowed to transform ELS into a modularized, more simplified, and standardized surgery, to upgrade surgical skills, to improve peri-operative outcome and long-term survival, to increase the capability of surgeons to select more complex diseases and to expand the level of medical service to the population. This review highlights the Chinese contributions to the field of ELS, focusing thereby on features of different surgical types, technical innovations, disease selection and surgical indication, patient prognosis and future perspectives.
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Affiliation(s)
- Abudusalamu Aini
- Hepatopancreatobiliary Center, Organ Transplantation Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing 102218, China; Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Tsinghua University, Beijing 100084, China; Research Unit of Precision Hepatobiliary Surgery Paradigm, Chinese Academy of Medical Sciences, Beijing 100010, China; Institute for Organ Transplantation and Bionics, Institute for Precision Medicine, School of Clinical Medicine, Tsinghua University, Beijing 100010, China
| | - Qian Lu
- Hepatopancreatobiliary Center, Organ Transplantation Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing 102218, China; Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Tsinghua University, Beijing 100084, China; Research Unit of Precision Hepatobiliary Surgery Paradigm, Chinese Academy of Medical Sciences, Beijing 100010, China; Institute for Organ Transplantation and Bionics, Institute for Precision Medicine, School of Clinical Medicine, Tsinghua University, Beijing 100010, China
| | - Hao Wen
- Hepatobiliary & Echinococcosis Surgery, Digestive & Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Wen-Tao Wang
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Tuerganaili Aji
- Hepatobiliary & Echinococcosis Surgery, Digestive & Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Zhi-Yu Chen
- Department of Hepatobiliary Surgery, Southwest Hospital, The Army Medical University, Chongqing 100089, China
| | - Lei-Da Zhang
- Department of Hepatobiliary Surgery, Southwest Hospital, The Army Medical University, Chongqing 100089, China
| | - Zhan-Yu Yang
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese People's Army General Hospital, Beijing 400038, China
| | - Jia-Yin Yang
- Liver Transplantation Center & Organ Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Hai-Ning Fan
- Hepatopancreatobiliary Surgery, School of Clinical Medicine, Qinghai University Affiliated Hospital, Xining 810006, China
| | - Wei-Lin Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Zhejiang Univeristy School of Medicine, Hangzhou 310009, China
| | - Xiang-Cheng Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Yu Zhang
- Department of Hepatobiliary Surgery, Sichuan Provincial People's Hospital, Chengdu 610072, China
| | - Jia-Hong Dong
- Hepatopancreatobiliary Center, Organ Transplantation Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing 102218, China; Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Tsinghua University, Beijing 100084, China; Research Unit of Precision Hepatobiliary Surgery Paradigm, Chinese Academy of Medical Sciences, Beijing 100010, China; Institute for Organ Transplantation and Bionics, Institute for Precision Medicine, School of Clinical Medicine, Tsinghua University, Beijing 100010, China.
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4
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Aini A, Lu Q, Chen Z, Yang Z, Liu Z, Zhang L, Dong J. Ex-vivo Liver Resection and Autotransplantation for Liver Malignancy : A Large Volume Retrospective Clinical Study. Ann Surg 2024; 280:879-886. [PMID: 39145635 DOI: 10.1097/sla.0000000000006505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
OBJECTIVE To assess the effectiveness of optimized ex-vivo liver resection and autotransplantation (ELRA) for treating liver malignancies. BACKGROUND ELRA is a promising surgery for radical resection of conventionally unresectable tumors, despite the disappointing long-term prognosis during its developmental stages. A recent multicenter study reported 5-year overall and disease-free survival rates of 28% and 20.8%, respectively. METHODS We retrospectively analyzed data of patients who underwent ELRA for advanced liver cancers between 2009 and 2022. We applied ELRA via our novel surgical indication classification system where the surgical risk with curative intent for advanced liver malignancy was controllable using the ex-vivo approach. The ELRA was optimized for determinacy, predictability, and controllability via the precision liver surgery paradigm. RESULTS Thirty-seven cases with liver malignancies were enrolled. The operative time and anhepatic phase duration were 649.6±200.0 and 261.2±74.5 minutes, respectively, while the intraoperative blood loss was 1902±1192 mL. Negative resection margins were achieved in all patients, and the 90-day morbidity at Clavien-Dindo IIIa/IIIb and mortality rates were 27.0% and 24.3%. Post-ELRA 1-, 3-, and 5-year actual overall survival rates were 62.2%, 37.8%, and 35.1%, respectively, and 1-, 3-, and 5-year actual disease-free survival rates were 43.2%, 24.3%, and 18.9%, respectively. CONCLUSIONS Long-term outcomes of ELRA under precision liver surgery for advanced liver malignancy were favorable. Appropriate criteria for disease selection and surgical indications and optimized procedures together can improve surgical treatment and patient prognosis.
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Affiliation(s)
- Abudusalamu Aini
- Hepatopancreatobiliary Center, Organ Transplantation Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
- Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Tsinghua University, Beijing, China
- School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Qian Lu
- Hepatopancreatobiliary Center, Organ Transplantation Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
- Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Tsinghua University, Beijing, China
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Institute for Organ Transplantation and Bionics, Institute for Precision Medicine of School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhiyu Chen
- Department of Hepatobiliary Surgery, Southwest Hospital, The Army Medical University, Chongqing, China
| | - Zhanyu Yang
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese People's Army General Hospital, Beijing, China
| | - Zhipeng Liu
- Department of Hepatobiliary Surgery, Southwest Hospital, The Army Medical University, Chongqing, China
| | - Leida Zhang
- Department of Hepatobiliary Surgery, Southwest Hospital, The Army Medical University, Chongqing, China
| | - Jiahong Dong
- Hepatopancreatobiliary Center, Organ Transplantation Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
- Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Tsinghua University, Beijing, China
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Institute for Organ Transplantation and Bionics, Institute for Precision Medicine of School of Clinical Medicine, Tsinghua University, Beijing, China
- Research Unit of Precision Hepatobiliary Surgery Paradigm, Chinese Academy of Medical Sciences, Beijing, China
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Tebala GD, Avenia S, Cirocchi R, Delvecchio A, Desiderio J, Di Nardo D, Duro F, Gemini A, Giuliante F, Memeo R, Nuzzo G. Turning points in the practice of liver surgery: A historical review. Ann Hepatobiliary Pancreat Surg 2024; 28:271-282. [PMID: 38752233 PMCID: PMC11341877 DOI: 10.14701/ahbps.24-039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 08/23/2024] Open
Abstract
The history of liver surgery is a tale of progressive resolution of issues presenting one after another from ancient times to the present days when dealing with liver ailments. The perfect knowledge of human liver anatomy and physiology and the development of a proper liver resective surgery require time and huge efforts and, mostly, the study and research of giants of their own times, whose names are forever associated with anatomical landmarks, thorough descriptions, and surgical approaches. The control of parenchymal bleeding after trauma and during resection is the second issue that surgeons have to resolve. A good knowledge of intra and extrahepatic vascular anatomy is a necessary condition to develop techniques of vascular control, paving the way to liver transplantation. Last but not least, the issue of residual liver function after resection requires advanced techniques of volume redistribution through redirection of blood inflow. These are the same problems any young surgeon would face when approaching liver surgery for the first time. Therefore, obtaining a wide picture of historical evolution of liver surgery could be a great starting point to serve as an example and a guide.
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Affiliation(s)
| | - Stefano Avenia
- Department of General and Emergency Surgery, “S.Maria della Misericordia” Hospital Trust, Perugia, Italy
| | - Roberto Cirocchi
- Department of Digestive and Emergency Surgery, “S.Maria” Hospital Trust, Terni, Italy
| | - Antonella Delvecchio
- Department of Hepatobiliary Surgery, “F.Miulli” Hospital, Acquaviva delle Fonti, Italy
| | - Jacopo Desiderio
- Department of Digestive and Emergency Surgery, “S.Maria” Hospital Trust, Terni, Italy
| | - Domenico Di Nardo
- Department of Digestive and Emergency Surgery, “S.Maria” Hospital Trust, Terni, Italy
| | - Francesca Duro
- Department of Digestive and Emergency Surgery, “S.Maria” Hospital Trust, Terni, Italy
| | - Alessandro Gemini
- Department of Digestive and Emergency Surgery, “S.Maria” Hospital Trust, Terni, Italy
| | - Felice Giuliante
- Department of Hepatobiliary Surgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Riccardo Memeo
- Department of Hepatobiliary Surgery, “F.Miulli” Hospital, Acquaviva delle Fonti, Italy
| | - Gennaro Nuzzo
- Catholic University of the Sacred Heart, Milan, Italy
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Ahuja M, Joshi K, Coldham C, Muiesan P, Dasari B, Abradelo M, Marudanayagam R, Mirza D, Isaac J, Bartlett D, Chatzizacharias NA, Sutcliffe RP, Roberts KJ. Hepatic vein reconstruction during hepatectomy: A feasible and underused technique. Hepatobiliary Pancreat Dis Int 2024; 23:421-427. [PMID: 38278672 DOI: 10.1016/j.hbpd.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 12/12/2023] [Indexed: 01/28/2024]
Affiliation(s)
- Manish Ahuja
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Kunal Joshi
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chris Coldham
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paulo Muiesan
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bobby Dasari
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Manuel Abradelo
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ravi Marudanayagam
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Darius Mirza
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Isaac
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Bartlett
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nikolaos A Chatzizacharias
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Robert P Sutcliffe
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith J Roberts
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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7
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Di Benedetto F, Magistri P, Marcon F, Soubrane O, Pedreira Mello F, Santos Coelho J, Fernandez AR, Frassoni S, Bagnardi V, Singhal A, Rotellar F, Hernandez-Alejandro R, Alikhanov R, de Souza M Fernandes E, Cauchy F, Muiesan P, Di Sandro S, Pinto Marques H. Vena cava replacement and major hepatectomy for liver tumors: international multicenter retrospective cohort study. Int J Surg 2024; 110:4286-4296. [PMID: 38608195 PMCID: PMC11254261 DOI: 10.1097/js9.0000000000001386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/11/2024] [Indexed: 04/14/2024]
Abstract
INTRODUCTION Involvement of the inferior vena cava (IVC) and hepatic veins has been considered a relative contraindication to hepatic resection for primary and metastatic liver tumors. However, patients affected by tumors extending to the IVC have limited therapeutic options and suffer worsening of quality of life due to IVC compression. METHODS Cases of primary and metastatic liver tumors with vena cava infiltration from 10 international centers were collected (7 European, 1 US, 2 Brazilian, 1 Indian) were collected. Inclusion criteria for the study were major liver resection with concomitant vena cava replacement. Clinical data and short-term outcomes were analyzed. RESULTS Thirty-six cases were finally included in the study. Median tumor max size was 98 mm (range: 25-250). A biliary reconstruction was necessary in 28% of cases, while a vascular reconstruction other than vena cava in 34% of cases. Median operative time was 462 min (range: 230-750), with 750 median ml of estimated blood loss and a median of one pRBC transfused intraoperatively (range: 0-27). Median ICU stay was 4 days (range: 1-30) with overall in-hospital stay of 15 days (range: 3-46), postoperative CCI score of 20.9 (range: 0-100), 12% incidence of PHLF grade B-C. Five patients died in a 90-days interval from surgery, one due to heart failure, one due to septic shock, and three due to multiorgan failure. With a median follow-up of 17 months (interquartile range: 11-37), the estimated 5 years overall survival was 48% (95% CI: 27-66%), and 5-year cumulative incidence of tumor recurrence was 55% (95% CI: 33-73%). CONCLUSIONS Major liver resections with vena cava replacement can be performed with satisfactory results in expert HPB centers. This surgical strategy represents a feasible alternative for otherwise unresectable lesions and is associated with favorable prognosis compared to nonoperative management, especially in patients affected by intrahepatic cholangiocarcinoma.
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Affiliation(s)
- Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Marcon
- HPB Surgery and Liver Transplant, Queen Elizabeth Hospital, Birmingham, UK
| | - Olivier Soubrane
- Department of HPB and Liver Transplantation, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - Felipe Pedreira Mello
- Department of Surgery and Abdominal Organ Transplantation – Hospital Adventista Silvestre, Rio de Janeiro, Brazil
| | - Joao Santos Coelho
- Department of Surgery, Hepato-Biliary-Pancreatic and Transplantation Center, Curry Cabral Hospital, Lisbon, Portugal
| | - Andre Renaldo Fernandez
- Department of Surgery, Division of Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, New York
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Ashish Singhal
- Advanced Institute of Liver and Biliary Sciences, Fortis Hospitals, Delhi, NCR, India
| | - Fernando Rotellar
- Department of Surgery, HPB and Liver Transplantation Unit, University Clinic, Universidad de Navarra; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Roberto Hernandez-Alejandro
- Department of Surgery, Division of Transplantation and Hepatobiliary Surgery, University of Rochester Medical Center, Rochester, New York
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery and Department of Transplantation, Moscow Clinical Scientific Center, Moscow, Russia
| | - Eduardo de Souza M Fernandes
- Department of Surgery and Abdominal Organ Transplantation – Hospital Adventista Silvestre, Rio de Janeiro, Brazil
- Hepato-Pancreato-Biliary Unit and Transplant – DHR Health, McAllen, Texas, USA
| | - Francois Cauchy
- Department of HPB and Liver Transplantation, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - Paolo Muiesan
- HPB Surgery and Liver Transplant, Queen Elizabeth Hospital, Birmingham, UK
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Hugo Pinto Marques
- Department of Surgery, Hepato-Biliary-Pancreatic and Transplantation Center, Curry Cabral Hospital, Lisbon, Portugal
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Lv T, Xu G, Xu X, Wu G, Wan CF, Song JL, Yang J, Zhou YJ, Luo K, Wu H, Ye CJ, Yan LN, Lau WY, Yang JY. A novel remnant liver-first strategy for liver autotransplantation in patients with end-stage hepatic alveolar echinococcosis: a retrospective case series. Int J Surg 2023; 109:3262-3272. [PMID: 37994730 PMCID: PMC10651293 DOI: 10.1097/js9.0000000000000604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/02/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Ex vivo liver resection combined with autotransplantation is an effective therapeutic strategy for unresectable end-stage hepatic alveolar echinococcosis (HAE). However, ex vivo liver resection combined with autotransplantation is a technically demanding and time-consuming procedure associated with significant morbidity and mortality. The authors aimed to present our novel remnant liver-first strategy of in vivo liver resection combined with autotransplantation (IRAT) technique for treating patients with end-stage HAE. METHODS This retrospective study included patients who underwent IRAT between January 2014 and December 2020 at two institutions. Patients with end-stage HAE were carefully assessed for IRAT by a multidisciplinary team. The safety, feasibility, and outcomes of this novel technique were analyzed. RESULTS IRAT was successfully performed in six patients, with no perioperative deaths. The median operative time was 537.5 min (range, 501.3-580.0), the median anhepatic time was 59.0 min (range, 54.0-65.5), and the median cold ischemia time was 165.0 min (range, 153.8-201.5). The median intraoperative blood loss was 700.0 ml (range, 475.0-950.0). In-hospital complications occurred in two patients. No Clavien-Dindo grade III or higher complications were observed. At a median follow-up of 18.6 months (range, 15.4-76.0) , all patients were alive. No recurrence of HAE was observed. CONCLUSION The remnant liver-first strategy of IRAT is feasible and safe for selected patients with end-stage HAE. The widespread adoption of this novel technique requires further studies to standardize the operative procedure and identify patients who are most likely to benefit from it.
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Affiliation(s)
- Tao Lv
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Gang Xu
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Xi Xu
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Gang Wu
- Department of Hepatobiliary Surgery, Qinghai Provincial People’s Hospital, Xining
| | - Chen-Fei Wan
- Department of Hepatobiliary Surgery, Qinghai Provincial People’s Hospital, Xining
| | - Jiu-Lin Song
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Jian Yang
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Yong-Jie Zhou
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Kui Luo
- Department of Radiology, Huaxi MR Research Center (HMRRC), National Clinical Research Center for Geriatrics, Frontiers Science Center for Disease-Related Molecular Network, State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu
| | - Hong Wu
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Cheng-Jie Ye
- Department of Hepatobiliary Surgery, Qinghai Provincial People’s Hospital, Xining
| | - Lv-Nan Yan
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
| | - Wan-Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, People’s Republic of China
| | - Jia-Yin Yang
- Liver Transplant Center, Organ Transplant Center
- Laboratory of Liver Transplantation, Key Laboratory of Transplant Engineering and Immunology, NHC
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9
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Fard-Aghaie MH, Laengle J, Wagner KC, Reese T, Wirtz S, Oldhafer KJ. Liver surgery in the 2020s: ante-situm and in-situ resection are still indicated - A single-center study. HPB (Oxford) 2023; 25:1030-1039. [PMID: 37328365 DOI: 10.1016/j.hpb.2023.05.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/13/2023] [Accepted: 05/27/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Tumor infiltration of the hepatic outflow comprising all three hepatic veins and the inferior vena cava remains a surgical challenge. Liver resection under total vascular exclusion with or without extracorporeal bypass has been described as a therapeutic option for these tumors. Here, we present our experience with these complex surgical methods. METHODS We searched our database for patients treated with an in-situ or ante-situm liver resection (ISR and ASR, respectively) with extracorporeal bypass. We collected demographic and perioperative data. RESULTS From January 2010 to December 2021, we performed 2122 liver resections. Nine patients were treated with ASR and five were treated with ISR. Out of these 14 patients, six had colorectal liver metastases, six had cholangiocarcinoma, and two had non-colorectal liver metastases. The median operative time and bypass time in all patients were 536.5 and 150 min, respectively. Compared with ISR, ASR required a longer operative time (ASR 586 min and ISR 495 min) and a longer bypass time (ASR 155 min and ISR 122 min). Morbidity (Clavien-Dindo grade > 3A adverse events) occurred in 78.5% of patients. 90-day postoperative mortality was 7%. Median overall survival was 33 months. Seven patients experienced recurrence. In these patients, median disease-free survival was 9 months. CONCLUSION Resection of tumors infiltrating the hepatic outflow poses a high risk for patients. However, with rigorous selection and an experienced perioperative team, these patients can be treated surgically with reasonable oncological outcomes.
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Affiliation(s)
- Mohammad H Fard-Aghaie
- Asklepios Hospital Barmbek, Department of Surgery, Division of HBP Surgery, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Johannes Laengle
- Asklepios Hospital Barmbek, Department of Surgery, Division of HBP Surgery, Semmelweis University Campus Hamburg, Hamburg, Germany; Division of Visceral Surgery, Department of General Surgery, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Kim C Wagner
- Asklepios Hospital Barmbek, Department of Surgery, Division of HBP Surgery, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Tim Reese
- Asklepios Hospital Barmbek, Department of Surgery, Division of HBP Surgery, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Sebastian Wirtz
- Asklepios Hospital Barmbek, Department of Anesthesiology, Hamburg, Germany
| | - Karl J Oldhafer
- Asklepios Hospital Barmbek, Department of Surgery, Division of HBP Surgery, Semmelweis University Campus Hamburg, Hamburg, Germany.
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Yuan J, Chen X, Hou L, Wang H, Zhou Y, Pang M, YangDan C, Wang Z, Fan H. Single-center experience of Ex vivo liver resection and autotransplantation for complex hepatic alveolar echinoccosis. Front Surg 2023; 10:1089788. [PMID: 36874451 PMCID: PMC9975350 DOI: 10.3389/fsurg.2023.1089788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/18/2023] [Indexed: 02/17/2023] Open
Abstract
Objective To summarize the single-centre experience of Ex vivo Liver Resection and Autotransplantation (ELRA) to treat end-stage hepatic alveolar echinococcosis (HAE). Methods Retrospective analysis of clinical data and follow-up data of 13 patients admitted to the Affiliated Hospital of Qinghai University from January 2015 to December 1, 2020, with the Ex vivo Liver Resection and Autotransplantation for hepatic alveolar echinococcosis. Result 13 patients underwent successful total/ semi-ex-vivo liver resection combined with Ex vivo Liver Resection and Autotransplantation with no intra-operative deaths. the median standard liver volume was 1,118 ml (1,085-1,206.5 ml); the median residual liver volume was 634 ml (526.5-1,338 ml); The median weight of the autograft was 845.8 g (619.5-1,020.5 g), the median operation time was 14.5 h (11.5-16.15 h); the median anhepatic period time was 290 min (257-312.5 min). The median intraoperative blood loss was 1,900 ml (1,300-3,500 ml); the median number of erythrocyte suspensions entered was 7.5 u (6-9u). The median length of hospital stay was 32 days (24-40 days). Postoperative complications occurred in 9 patients during hospitalization,with 7 patients graded at grade III or higher by Clavien-Dindo; 4 patients died postoperatively. 1 patient had recurrent abdominal distension with massive thoracoabdominal fluid and coagulation dysfunction 8 months after surgery and was considered to have small liver syndrome. 1 patient developed HAE recurrence during the follow-up, which was considered intraoperative incisional implantation. Conclusion ELRA is one of the most valuable therapeutic measures for the treatment of end-stage complicated hepatic alveolar echinococcosis. Precise preoperative assessment of liver function, individualized intraoperative duct reconstruction, and precise management of the postoperative disease can achieve better treatment results.
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Affiliation(s)
- Jiaqi Yuan
- Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Qinghai University, Qinghai, China
- Qinghai Province Research Key Laboratory for Echinococcosis, Qinghai, China
- Department of Gastroenterology, Xining Second People's Hospital, Xining, Qinghai, China
| | - Xiaobin Chen
- Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Qinghai University, Qinghai, China
- Qinghai Province Research Key Laboratory for Echinococcosis, Qinghai, China
| | - Lizhao Hou
- Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Qinghai University, Qinghai, China
- Qinghai Province Research Key Laboratory for Echinococcosis, Qinghai, China
| | - Haijiu Wang
- Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Qinghai University, Qinghai, China
- Qinghai Province Research Key Laboratory for Echinococcosis, Qinghai, China
| | - Ying Zhou
- Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Qinghai University, Qinghai, China
- Qinghai Province Research Key Laboratory for Echinococcosis, Qinghai, China
| | - Mingquan Pang
- Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Qinghai University, Qinghai, China
- Qinghai Province Research Key Laboratory for Echinococcosis, Qinghai, China
| | - CaiRang YangDan
- Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Qinghai University, Qinghai, China
- Qinghai Province Research Key Laboratory for Echinococcosis, Qinghai, China
| | - Zhixin Wang
- Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Qinghai University, Qinghai, China
- Qinghai Province Research Key Laboratory for Echinococcosis, Qinghai, China
| | - Haining Fan
- Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Qinghai University, Qinghai, China
- Qinghai Province Research Key Laboratory for Echinococcosis, Qinghai, China
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11
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Tverdov IV, Akhaladze DG. [Transplantation technologies in pediatric liver resections]. Khirurgiia (Mosk) 2023:74-80. [PMID: 36583497 DOI: 10.17116/hirurgia202301174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Liver resections with transplantation technologies have been recognized as safe procedures for the last decades. These procedures may be the only curative option or alternative to liver transplantation in some cases. Moreover, these surgeries can also provide parenchyma-sparing liver resection. Nevertheless, higher postoperative morbidity and mortality compared to traditional hepatectomy require careful research of indications for liver resections with transplantation technologies, the role of vascular liver exclusion, methods of vascular reconstructions with or without anticoagulation. These challenges are more important for pediatric surgery due to few literature data on this issue. This review is devoted to liver resections with transplantation technologies.
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Affiliation(s)
- I V Tverdov
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - D G Akhaladze
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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12
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From liver surgery to liver transplant surgery: new developments in autotransplantation. Curr Opin Organ Transplant 2022; 27:337-345. [PMID: 36354260 DOI: 10.1097/mot.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE OF REVIEW In spite of substantial technical improvements and conceptual revolutions in advanced liver surgery, there are still straitened circumstances that pose difficulties for in-situ liver resections. Ex-vivo liver resection and autotransplantation (ELRA) is a hybrid technique combining experiences from conventional liver surgery and liver transplantation. This technique is becoming more comprehensive and popular among leading centers recently. RECENT FINDINGS Short-term and long-term outcomes are now the focus of the technique after more than a decade of cumulative progress and technical evolution. As the 5-year survival nowadays reaches over 80%, this technique is believed to be beneficial for advanced tumors. In recent years, ELRA has been applied by more centers on larger scales, and the learning curve was set at 53 cases. Progresses in disease selection, surgical indications, individualized outflow reconstruction, or autograft implantation, management of co-morbidities (e.g., Budd-Chiari syndrome, caval and/or neighboring organ involvements, obstructive jaundice) propelled the development of the technique. SUMMARY This hybrid liver surgery will benefit for carefully selected patients presented with advanced benign diseases and well-differentiated malignancies.
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Sun T, Wang T, Qiu Y, Shen S, Yang X, Yang Y, Huang B, Wang W. A Sarcopenia-Based Prediction Model for Postoperative Complications of ex vivo Liver Resection and Autotransplantation to Treat End-Stage Hepatic Alveolar Echinococcosis. Infect Drug Resist 2021; 14:4887-4901. [PMID: 34848980 PMCID: PMC8627200 DOI: 10.2147/idr.s340478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/11/2021] [Indexed: 02/05/2023] Open
Abstract
Background Sarcopenia and visceral adiposity have been shown to be associated with postoperative complications in numerous diseases. However, their effects on the postoperative complications of end-stage hepatic alveolar echinococcosis (HAE) patients undergoing ex vivo liver resection and autotransplantation (ELRA) remain unclear. Methods This retrospective study included 101 end-stage HAE patients who underwent ELRA from January 2014 to August 2020. We measured the skeletal muscle and adipose tissue of all patients at the level of the third lumbar vertebra on plain abdominal computed tomography (CT) images and subsequently derived an equation via least absolute shrinkage and selection operator (LASSO) regression analysis to calculate the sarcopenia score. Univariate and multivariate regression were performed to reveal the relationship between major postoperative complications and perioperative clinical data, and the obtained nomogram was validated with the bootstrapping method. Results The sarcopenia score was constructed as a personalized indicator to evaluate sarcopenia and visceral adiposity in each patient. Logistic regression analysis finally selected duration from primary diagnosis to obvious symptoms (OR=1.024, 95% CI, 1.007-1.042), surgical time (OR=1.003, 95% CI, 0.999-1.007) and sarcopenia score (OR=4.283, 95% CI, 1.739-10.551) as independent risk factors for predicting major postoperative complications following ELRA for end-stage HAE patients. The area under the receiver operating characteristic curve (AUROC) of 0.807 (95% CI, 0.720-0.895) and the calibration curve for this prediction model were satisfactory. Conclusion The sarcopenia score, which systematically evaluates the skeletal muscle and adipose tissue of end-stage HAE patients, was a significant predictive factor for major postoperative complications of ELRA. Relevant interventions should be conducted for those who have a high risk of postoperative complications according to the nomogram.
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Affiliation(s)
- Ting Sun
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Tao Wang
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Yiwen Qiu
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Shu Shen
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Xianwei Yang
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Yi Yang
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Wentao Wang
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, People's Republic of China
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Chen J, Wei L, Chen TW, Li R, Zhang XM, Deng CM, Zhang Y, Xiong J, Li XZ, Li ZH. Triphase contrast-enhanced CT to evaluate indications for autologous liver transplantation in patients with end-stage hepatic alveolar echinococcosis. Sci Rep 2021; 11:22096. [PMID: 34764382 PMCID: PMC8586367 DOI: 10.1038/s41598-021-01586-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 11/01/2021] [Indexed: 02/05/2023] Open
Abstract
Autologous liver transplantation (ALT) to cure end-stage hepatic alveolar echinococcosis (HAE) requires that hepatobiliary surgeons understand the invasion of intrahepatic structure and adjacent tissues or organs. Triphase contrast-enhanced CT of the liver has been widely used for diagnosis and preoperative evaluation of HAE. Three-dimensional (3D) reconstruction allows for accurate measurement of remnant liver volume (RLV). The objective of the study was to evaluate value of triphase contrast-enhanced CT together with 3D reconstruction in preoperative evaluation of indications for ALT in patients with end-stage HAE. This cohort include twenty-one consecutive patients with end-stage HAE, who preoperatively underwent triphase enhanced CT together with 3D reconstruction for ALT. To depict the indications, the 2D image data were reviewed statistically focusing on porta hepatis invasion, retrohepatic vena cava (RHVC) involvement and degrees of intrahepatic vessel invasion, and the 3D reconstruction was performed to obtain ratio of RLV to standard liver volume (SLV). The results showed that 95.24% patients (20/21) had porta hepatis invasion. When lesions located in right liver lobe, porta hepatis invasion occurred most commonly in the second and third porta hepatis (7/10), whereas the first, second and third porta hepatis were most commonly invaded by lesions in the right and caudate / left medial liver lobes (7/11) (P < 0.05). The mean value of longitudinal invasion of RHVC was 8.0 cm, and 95.2% (20/21) of patients had RHVC invasion with ≥ 180° circumferential invasion. As for the important vascular events, moderate and severe invasion occurred most commonly in the right hepatic vein, right branch of portal vein and RHVC each in 95.2% (20/21) patients (P < 0.05). We also found that preoperative CT had a good agreement with intraoperative findings in assessing intrahepatic vascular involvement by HAE (kappa index = 0.77). The estimated average ratio of RLV to SLV was 0.95 (range, 0.43–1.62). In conclusion, the 2D contrast-enhanced CT could well depict anatomic location and size of HAE, and invasion of porta hepatis and vascular by this disease, and involvement of other adjacent organs and tissues. Above all, 3D reconstruction could accurately measure RLV in patients with end-stage HAE for ALT.
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Affiliation(s)
- Jing Chen
- Sichuan Key Laboratory of Medical Imaging, and Department of Radiology, Affiliated Hospital of North Sichuan Medical College, 1# Maoyuan Road, Shunqing District, Nanchong, 637000, Sichuan, China
| | - Li Wei
- Department of Radiology, Ganzi Hospital, West China Hospital of Sichuan University (Ganzi Tibetan Autonomous Prefecture People's Hospital), 94# Xida Road, Kangding, Ganzi, 626000, Sichuan, China
| | - Tian-Wu Chen
- Sichuan Key Laboratory of Medical Imaging, and Department of Radiology, Affiliated Hospital of North Sichuan Medical College, 1# Maoyuan Road, Shunqing District, Nanchong, 637000, Sichuan, China.
| | - Rui Li
- Sichuan Key Laboratory of Medical Imaging, and Department of Radiology, Affiliated Hospital of North Sichuan Medical College, 1# Maoyuan Road, Shunqing District, Nanchong, 637000, Sichuan, China
| | - Xiao-Ming Zhang
- Sichuan Key Laboratory of Medical Imaging, and Department of Radiology, Affiliated Hospital of North Sichuan Medical College, 1# Maoyuan Road, Shunqing District, Nanchong, 637000, Sichuan, China
| | - Chun-Mei Deng
- Department of Radiology, Ganzi Hospital, West China Hospital of Sichuan University (Ganzi Tibetan Autonomous Prefecture People's Hospital), 94# Xida Road, Kangding, Ganzi, 626000, Sichuan, China
| | - Yi Zhang
- Department of Radiology, Ganzi Hospital, West China Hospital of Sichuan University (Ganzi Tibetan Autonomous Prefecture People's Hospital), 94# Xida Road, Kangding, Ganzi, 626000, Sichuan, China
| | - Jing Xiong
- Department of Radiology, Ganzi Hospital, West China Hospital of Sichuan University (Ganzi Tibetan Autonomous Prefecture People's Hospital), 94# Xida Road, Kangding, Ganzi, 626000, Sichuan, China
| | - Xian-Zhong Li
- Department of Radiology, Ganzi Hospital, West China Hospital of Sichuan University (Ganzi Tibetan Autonomous Prefecture People's Hospital), 94# Xida Road, Kangding, Ganzi, 626000, Sichuan, China
| | - Zhi-Hong Li
- Department of Radiology, Ganzi Hospital, West China Hospital of Sichuan University (Ganzi Tibetan Autonomous Prefecture People's Hospital), 94# Xida Road, Kangding, Ganzi, 626000, Sichuan, China
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Radulova-Mauersberger O, Weitz J, Riediger C. Vascular surgery in liver resection. Langenbecks Arch Surg 2021; 406:2217-2248. [PMID: 34519878 PMCID: PMC8578135 DOI: 10.1007/s00423-021-02310-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/18/2021] [Indexed: 01/04/2023]
Abstract
Vascular surgery in liver resection is a standard part of liver transplantation, but is also used in oncological liver surgery. Malignant liver tumors with vascular involvement have a poor prognosis without resection. Surgery is currently the only treatment to provide long-term survival in advanced hepatic malignancy. Even though extended liver resections are increasingly performed, vascular involvement with need of vascular reconstruction is still considered a contraindication for surgery in many institutions. However, vascular resection and reconstruction in liver surgery-despite being complex procedures-are safely performed in specialized centers. The improvements of the postoperative results with reduced postoperative morbidity and mortality are a result of rising surgical and anesthesiological experience and advancements in multimodal treatment concepts with preconditioning measures regarding liver function and systemic treatment options. This review focuses on vascular surgery in oncological liver resections. Even though many surgical techniques were developed and are also used during liver transplantation, this special procedure is not particularly covered within this review article. We provide a summary of vascular reconstruction techniques in oncological liver surgery according to the literature and present also our own experience. We aim to outline the current advances and standards in extended surgical procedures for liver tumors with vascular involvement established in specialized centers, since curative resection improves long-term survival and shifts palliative concepts to curative therapy.
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Affiliation(s)
- Olga Radulova-Mauersberger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Carina Riediger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
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Wu G, Wu Y, Wang M, Zhang W, Liu C, Liang T. Vascular reconstruction of segmental intestinal grafts using autologous internal iliac vessels. Gastroenterol Rep (Oxf) 2021; 9:350-356. [PMID: 34567567 PMCID: PMC8460098 DOI: 10.1093/gastro/goab016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 11/04/2020] [Accepted: 11/26/2020] [Indexed: 11/12/2022] Open
Abstract
Background The aim of this study was to assess whether the autologous internal iliac artery and vein could be used as an interpositional graft for vascular reconstruction in segmental intestinal allografts and autografts. Methods Thirty-four intestinal transplants (19 living-related allografts and 15 autografts) were conducted in our programs between January 2011 and January 2019. Patient characteristics, type of vascular reconstruction, and post-operative complications were reviewed. Results There were 20 males and 14 females with a median age of 35 years. Of 34 grafts, 22 (64.7%) (11 allografts and 11 autografts) were revascularized using the autologous internal iliac artery and vein for reconstruction. Vascular reconstruction on the back table took 21 ± 6 min to complete. Both total operative time and cold ischemia time tended to be longer in the vascular-reconstruction group than in the direct-anastomosis group (530 ± 226 vs 440 ± 116 and 159 ± 49 vs 125 ± 66 min, respectively), but these differences were not significant. The incidence of vascular thrombosis tended to be higher in the direct-anastomosis group than in the vascular-reconstruction group (16.7% vs 0%, P = 0.118). At a median follow-up of 36.9 months, no stenosis or pseudoaneurysms developed. In 19 allografts, acute rejection occurred in 4 (21.1%) and chronic rejection occurred in 1 (5.2%). Conclusions Our results indicate that the use of an autologous internal iliac interposition graft greatly facilitates intestinal graft implantation and minimizes the risk of vascular complications.
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Affiliation(s)
- Guosheng Wu
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Yinglun Wu
- Section of Plastic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Mian Wang
- State Key Laboratory of Cancer Biology & National Clinical Research Center for Digestive Diseases, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Wentong Zhang
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Chaoxu Liu
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Tingbo Liang
- Intestinal Transplant Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
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Wang C, Qiu Y, Wang W. Application of ex vivo liver resection and autotransplantation in treating Budd-Chiari syndrome secondary to end-stage hepatic alveolar echinococcosis: A case series. Medicine (Baltimore) 2021; 100:e27075. [PMID: 34449508 PMCID: PMC8389916 DOI: 10.1097/md.0000000000027075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 08/12/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Secondary Budd-Chiari syndrome (BCS) occurs due to a blockage in the liver caused by invasion or compression by a large lesion. Conventional treatments for BCS do not solve practical problems, wherease liver transplantation has been only applied as a last-resort therapy and as the only opportunity for a radical cure. We explored the feasibility of applying ex vivo liver resection and autotransplantation (ELRA) for the new indications of treating patients with end-stage hepatic alveolar echinococcosis (HAE). Our center has firstly proposed the idea and successfully treated the 49 patients with HAE. This article for the first time reports the application of ELRA in treating patients with BCS secondary to HAE. METHODS According to the degree of lesion invasion and surgical options, 11 patients were divided into 4 types. These 11 patients had large lesions that invaded the second and third hilum of the caudate lobe and involved the confluence of the hepatic vein and the inferior vena cava, suprahepatic vena cava, or at least 2 hepatic veins and led to secondary BCS. The aim of the present work was to report 11 patients with life-threatening diseases who underwent ELRA (ex vivo liver resection and autotransplantation) for secondary BCS, to propose a classification system for secondary BCS, and to suggest that secondary BCS is an indication for ELRA. RESULTS Eleven patients successfully underwent ELRA without intraoperative mortality. The median autograft weight was 690 g (440-950 g); operative time was 12.5 hours (9.4-16.5 hours); Postoperative hospital stay was 15 days (7-21 days). Clavien-Dindo grade IIIa or higher postoperative complications occurred in only 5 patients. CONCLUSIONS This article for the first time reports the application of ELRA in treating patients with BCS secondary to HAE, not only provides new ideas for alternative treatments of secondary BCS, but also provides a classification system for secondary BCS. This article describes the technical process of outflow tract reconstruction and the experience for expanding the indications for ELRA. Our study demonstrated that ELRA is well feasible for treatment of BCS secondary to advanced HAE.
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Affiliation(s)
- Cong Wang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province
- Department of Hepatopancreatobiliary Surgery, Affiliated Hospital of Qinghai University, Xining, Qinghai Province, China
| | - Yiwen Qiu
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province
| | - WenTao Wang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu, Sichuan Province
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Alikhanov R, Dudareva A, Trigo MÁ, Serrablo A. Vascular Resection for Intrahepatic Cholangiocarcinoma: Current Considerations. J Clin Med 2021; 10:jcm10173829. [PMID: 34501276 PMCID: PMC8432051 DOI: 10.3390/jcm10173829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Intrahepatic cholangiocarcinoma (iCCA) accounts for approximately 10% of all primary liver cancers. Surgery is the only potentially curative treatment, even in cases of macrovascular invasion. Since resection offers the only curative chance, even extended liver resection combined with complex vascular or biliary reconstruction of the surrounding organs seems justified to achieve complete tumour removal. In selected cases, the major vascular resection is the only change to try getting the cure. The best results are achieved by the referral centre with a wide experience in complex liver surgery, such as ALPPS procedure, IVC resection, and ante-situ and ex-situ resections. However, despite aggressive surgery, tumour recurrence occurs frequently and long-term oncological results are very poor. This suggests that significant progress in prognosis cannot be expected by surgery alone. Instead, multimodal treatment including neoadjuvant chemotherapy, radiotherapy, and subsequent adjuvant treatment for iCCA seem to be necessary to improve results.
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Affiliation(s)
- Ruslan Alikhanov
- Department of Liver and Pancreatic Surgery, Department of Transplantation, Moscow Clinical Scientific Centre, 111123 Moscow, Russia;
| | - Anna Dudareva
- Department of Vascular Surgery, Moscow Clinical Scientific Centre, 111123 Moscow, Russia;
| | - Miguel Ángel Trigo
- Department of Pathology, Miguel Servet University Hospital, 50009 Zaragoza, Spain;
| | - Alejandro Serrablo
- HPB Surgical Division, Miguel Servet University Hospital, 50009 Zaragoza, Spain
- Correspondence:
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Angelico R, Sensi B, Parente A, Siragusa L, Gazia C, Tisone G, Manzia TM. Vascular Involvements in Cholangiocarcinoma: Tips and Tricks. Cancers (Basel) 2021; 13:3735. [PMID: 34359635 PMCID: PMC8345051 DOI: 10.3390/cancers13153735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 01/04/2023] Open
Abstract
Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract. To date, surgical treatment remains the only hope for definitive cure of CCA patients. Involvement of major vascular structures was traditionally considered a contraindication for resection. Nowadays, selected cases of CCA with vascular involvement can be successfully approached. Intrahepatic CCA often involves the major hepatic veins or the inferior vena cava and might necessitate complete vascular exclusion, in situ hypothermic perfusion, ex situ surgery and reconstruction with autologous, heterologous or synthetic grafts. Hilar CCA more frequently involves the portal vein and hepatic artery. Resection and reconstruction of the portal vein is now considered a relatively safe and beneficial technique, and it is accepted as a standard option either with direct anastomosis or jump grafts. However, hepatic artery resection remains controversial; despite accumulating positive reports, the procedure remains technically challenging with increased rates of morbidity. When arterial reconstruction is not possible, arterio-portal shunting may offer salvage, while sometimes an efficient collateral system could bypass the need for arterial reconstructions. Keys to achieve success are represented by accurate selection of patients in high-volume referral centres, adequate technical skills and eclectic knowledge of the various possibilities for vascular reconstruction.
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Affiliation(s)
- Roberta Angelico
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
| | - Bruno Sensi
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
| | - Alessandro Parente
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham B15 2TH, UK
| | - Leandro Siragusa
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
| | - Carlo Gazia
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
| | - Giuseppe Tisone
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
| | - Tommaso Maria Manzia
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
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Jiang T, Ran B, Guo Q, Zhang R, Duan S, Zhong K, Wen H, Shao Y, Aji T. Use of the ligamentum teres hepatis for outflow reconstruction during ex vivo liver resection and autotransplantation in patients with hepatic alveolar echinococcosis: A case series of 24 patients. Surgery 2021; 170:822-830. [PMID: 33994007 DOI: 10.1016/j.surg.2021.03.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/03/2021] [Accepted: 03/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with extensive hepatic alveolar echinococcosis might require ex vivo liver resection and autotransplantation to remove the lesion. Patients with extensive vascular invasion will need reconstruction, but the selection of the proper graft is complicated. This study aimed to investigate the effectiveness and adverse events of using the ligamentum teres hepatis as a vascular replacement graft in ex vivo liver resection and autotransplantation. METHODS This was a retrospective case series of patients with hepatic alveolar echinococcosis who underwent ex vivo liver resection and autotransplantation between August 2010 and October 2018 and in whom the ligamentum teres hepatis was used to repair the remnant liver. The operative outcomes, recurrence, and survival were examined. RESULTS Twenty-four patients were included (10 men, 14 women). The anhepatic period was 290 to 672 minutes (median of 450 minutes). The ratio of the remnant liver volume to the standard liver volume was 0.43 to 0.97 (median of 0.71). The blood loss was 1,000 (500-5,000) mL. The postoperative hospital stay was 23 (1-85) days. Of the 24 patients, 3 died after the operation, but those deaths were unrelated to liver vascular complications. CONCLUSION The ligamentum teres hepatis could be used as a vascular replacement graft in ex vivo liver resection and autotransplantation. It has the advantages of convenient specimen extraction, no donor site injury, and no immunological rejection, which has promising clinical application prospects.
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Affiliation(s)
- Tiemin Jiang
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Bo Ran
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Qiang Guo
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Ruiqing Zhang
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Shuai Duan
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Kai Zhong
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Hao Wen
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yingmei Shao
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Tuerganaili Aji
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
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Sapisochin G, Hibi T, Toso C, Man K, Berenguer M, Heimbach J, Greten TF, Pugh TJ, Dawson LA, Mazzaferro V. Transplant Oncology in Primary and Metastatic Liver Tumors: Principles, Evidence, and Opportunities. Ann Surg 2021; 273:483-493. [PMID: 33065633 DOI: 10.1097/sla.0000000000004071] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Transplant oncology defines any application of transplant medicine and surgery aimed at improving cancer patients' survival and/or quality of life. In practice, liver transplantation for selected hepato-biliary cancers is the only solid organ transplant with demonstrated efficacy in curing cancer. Four are the proposed future contributions of transplant oncology in hepato-biliary cancer (4-e). (1) evolutionary approach to cancer care that includes liver transplantation; (2) elucidation of self and non-self recognition systems, by linking tumor and transplant immunology; (3) exploration of innovative endpoints both in clinical and experimental settings taking advantage from the access to the entire liver explant; (4) extension of surgical limitation in the multidisciplinary approach to hepato-biliary oncology. The aim of this review is to define the principles of transplant oncology that may be applied to hepato-biliary cancer treatment and research, attempting to balance current evidences with future opportunities.
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Affiliation(s)
- Gonzalo Sapisochin
- Multi-Organ Transplant and HPB Surgical Oncology, Division of General Surgery, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Christian Toso
- Division of Abdominal Surgery and Hepato-pancreato-biliary Center, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Kwan Man
- Department of Surgery, HKU-SZH and LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, Ciberehd, IISLaFe and Facultad de Medicina, La Fe University Hospital, Valencia, Spain
| | - Julie Heimbach
- Department of Surgery Liver Transplant Program, Mayo Clinic, Rochester, Minnesota
| | - Tim F Greten
- Gastrointestinal Malignancy Section, Thoracic and Gastrointestinal Oncology Branch, Center for Cancer Research and NCI-CCR Liver Cancer Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Trevor J Pugh
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Vincenzo Mazzaferro
- HPB Surgery and Liver Transplantation, Department of Oncology, University of Milan, Milan, Italy and Istituto Nazionale Tumori, Fondazione IRCCS, Milan, Italy
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The technical aspects of ex vivo hepatectomy with autotransplantation: a systematic review and meta-analysis. Langenbecks Arch Surg 2021; 406:2177-2200. [PMID: 33591451 DOI: 10.1007/s00423-021-02093-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/15/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE Ex vivo hepatectomy is the incorporation of liver transplant techniques in the non-transplant setting, providing opportunity for locally advanced tumors found conventionally unresectable. Because the procedure is rare and reports in the literature are limited, we sought to perform a systematic review and meta-analysis investigating technical variations of ex vivo hepatectomies. METHODS In the literature, there is a split in those performing the procedure between venovenous bypass (VVB) and temporary portacaval shunts (PCS). Of the 253 articles identified on the topic of ex vivo resection, 37 had sufficient data to be included in our review. RESULTS The majority of these procedures were performed for hepatic alveolar echinococcosis (69%) followed by primary and secondary hepatic malignancies. In 18 series, VVB was used, and in 18, a temporary PCS was performed. Comparing these two groups, intraoperative variables and morbidity were not statistically different, with a cumulative trend in favor of PCS. Ninety-day mortality was significantly lower in the PCS group compared to the VVB group (p=0.03). CONCLUSION In order to better elucidate these differences between technical approaches, a registry and consensus statement are needed.
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Ex Vivo Resection and Autotransplantation for Conventionally Unresectable Tumors - An 11-year Single Center Experience. Ann Surg 2020; 272:766-772. [PMID: 32833756 DOI: 10.1097/sla.0000000000004270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Ex vivo surgery may provide a chance at R0 resection for conventionally unresectable tumors. However, long-term outcomes have not been well documented. In this study, we analyze our 11-year outcomes to define its role. STUDY DESIGN We retrospectively analyzed 46 consecutive patients who underwent ex vivo surgery at our institution 2008-2019. RESULTS The types of tumors were: carcinoma (n = 20), sarcoma (n = 20) and benign to low grade tumor (n = 6). The type of ex vivo surgery was chosen based on tumor location and vascular involvement. The most commonly performed procedure was ex vivo hepatectomy (n = 18), followed by ex vivo resection and intestinal autotransplantation (n = 12), ex vivo Whipple procedure and liver autotransplantation (n = 8) and multivisceral ex vivo procedure (n = 7). Twenty-three patients (50%) are currently alive with median follow-up of 4.0-years (11 months-11.8 years). The overall survival was 70%/59%/52%, at 1-/3-/5-years, respectively. Patient survival for benign to low grade tumors, sarcoma, and carcinoma was 100%/100%/100%, 65%/60%/50%, and 65%/45%/40%, at 1-/3-/5-years, respectively. Ninety-one percent patients had R0 resection, and 57% had no recurrence to date with median follow-up of 3.1-years. Two patients (4.3%) died within 30 days due to sepsis and gastroduodenal artety (GDA) stump blowout. Two additional patients died between 30 and 90 days due to sepsis. Perioperative mortality in the last 23 consecutive cases was limited to 1 patient who died of sepsis between 30 and 90 days. CONCLUSIONS For a selected group of patients with conventionally unresectable tumors, ex vivo surgery can offer effective surgical removal with a reasonably low perioperative mortality at experienced centers.
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Zawistowski M, Nowaczyk J, Jakubczyk M, Domagała P. Outcomes of ex vivo liver resection and autotransplantation: A systematic review and meta-analysis. Surgery 2020; 168:631-642. [PMID: 32727659 DOI: 10.1016/j.surg.2020.05.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/11/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Many patients with hepatic tumors cannot benefit from resection owing to the difficult anatomic sites of their lesions. Some of these patients might be eligible for ex vivo liver resection and autotransplantation. This procedure consists of complete hepatectomy, extracorporeal liver resection, and autotransplantation of the remnant liver. METHODS Four databases were searched for studies reporting cases of ex vivo liver resection and autotransplantation. Outcomes of this procedure were evaluated by meta-analysis of proportions with random effects model and individual participant data analysis. RESULTS Fifty-three studies were assessed. Meta-analysis revealed an R0 resection rate of 93.4% (95% confidence interval: 81.0-97.9%, I2 = 0%), a frequency of major surgical complications of 24.5% (95% confidence interval, 16.9-34.3%, I2 = 26%), a 30-day mortality of 9.5% (95% confidence interval: 5.9-14.9%, I2 = 0%), and a 1-year survival of 78.4% (95% confidence interval: 62.2-88.8%, I2 = 64%). We were able to obtain the individual participant data in 244 patients; R0 resection was achieved in 98.6%, with no obvious difference between analyzed subgroups. The 30-day mortality and 1-year survivals were 7.9% and 82.1%, respectively. For groups with malignant and nonmalignant tumors, the 30-day mortalities were 11.3% vs. 6.3% (P = .181), and 1-year survivals were 65.0% vs. 89.7% (P < .001). When comparing those with malignant versus those with nonmalignant lesions, major surgical complications occurred in 50.0% vs. 21.0%; P < .001). Regression analysis revealed that outcomes of patients with benign tumors were better compared with those with malignant tumors (1-year survival, odds ratio: 4.629; 95% confidence interval: 2.181-10.097, P < .001). CONCLUSION Ex vivo liver resection and autotransplantation facilitates radical treatment in selected patients with conventionally unresectable hepatic tumors and normal liver function. The outcomes of treatment of malignant lesions appear to be less satisfactory.
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Affiliation(s)
| | | | - Michał Jakubczyk
- Decision Analysis and Support Unit, SGH Warsaw School of Economics, Warsaw, Poland
| | - Piotr Domagała
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
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Schlegel A, Sakuraoka Y, Motwani K, Gourevitch D, Sharif K, Isaac J, Almond M, Desai A, Muiesan P. Outcome after ex situ or ante situm liver resection with hypothermic perfusion and auto-transplantation: A single-centre experience in adult and paediatric patients. J Surg Oncol 2020; 122:1122-1131. [PMID: 32705679 DOI: 10.1002/jso.26116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 06/18/2020] [Accepted: 06/27/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Evolving surgical technology and medical treatment have led to an expansion of indications to enable resection of large hepatic tumours with involvement of other abdominal structures. METHODS Twelve extended liver and abdominal resections, either ex situ with auto-transplantation of the liver remnant or ante situm with veno-venous bypass (VVBP) were performed between 2016 and 2018. We describe our preoperative assessment, compare surgical strategies and assess outcomes. RESULTS The median age of the 10 adult patients was 50.5 years with a majority suffering from sarcoma-like tumours. The two paediatric patients were 3 and 8 years of age, both with hepatoblastoma. Two patients underwent ex situ resections with auto-transplantation of the liver remnant, and nine patients had ante situm tumour removal with the use of VVBP in four. All patients achieved a good immediate liver function. Local infection and acute kidney injury were found in two patients. One patient underwent biliary reconstruction for bile leak. Tumour recurrence was seen in seven patients (58.3%), with four lung metastases. Five patients died from tumour recurrence (41.7%) during the follow-up. CONCLUSION Extreme liver resections should be performed in experienced centres, where surgical subspecialties are available with access to cardiovascular support. Additionally, experience in split and living-donor liver transplantation is beneficial.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Yuhki Sakuraoka
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,Second Department of Surgery, Dokkyo Medical University, Tokyo, Japan
| | - Kanchan Motwani
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - David Gourevitch
- Midland Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Khalid Sharif
- Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - John Isaac
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Max Almond
- Midland Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Anant Desai
- Midland Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
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Zhang Y, Xie P, Yang C, Yang H, Liu J, Zhou G, Deng S, Lau WY. Percutaneous stenting of left hepatic vein followed by Ex vivo Liver Resection and Autotransplantation in a patient with hepatic alveolar echinococcosis with Budd-Chiari syndrome. Int J Surg Case Rep 2020; 68:251-256. [PMID: 32199250 PMCID: PMC7082604 DOI: 10.1016/j.ijscr.2020.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/02/2020] [Indexed: 12/21/2022] Open
Abstract
A metal mesh stent was placed in the left hepatic vein of a 45-year-old man who presented with Budd-Chiari syndrome in stage 1. After disappearance of ascites and improvement in liver function, ELRA was performed in stage 2. Follow-up examination at 6 months showed normal liver function and no evidence of recurrence. In selected patients with Budd-Chiari syndreme, percutaneous stenting followed by ELRA represent an curative treatment option. Background and aims Infiltration of hepatic venous outflow in hepatic alveolar echinococcosis can lead to development of Budd-Chiari syndrome. Medical treatment of this condition is generally unsatisfactory. Radical hepatic resection is impossible for extensive parasitic involvement of liver. This is a case report on a patient who was successfully treated with percutaneous stenting of left hepatic vein followed by Ex vivo Liver Resection and Autotransplantation (ELRA). Methods Using the transjugular approach, a metal mesh stent was placed in the left hepatic vein of a 45-year-old man who presented with Budd-Chiari syndrome. After disappearance of ascites and improvement in liver function, Ex vivo Liver Resection and Autotransplantation were performed. Results The patient underwent left hepatic vein stenting for Budd-Chiari syndrome without complication. Three months later, liver biopsy showed fibrous proliferation of interlobular portal areas and normal hepatic lobules. After successful Ex vivo Liver Resection and Autotransplantation, follow-up examination at 6 months showed normal liver function and no evidence of recurrence. Conclusions Allotransplantation is an accepted treatment for advanced hepatic alveolar echinococcosis with Budd-Chiari syndrome. However, shortage of organ donors and need for immunosuppression are challenging problems. In selected patients with hepatic vein stenoses presenting as Budd-Chiari syndreme, percutaneous stenting of hepatic veins followed by ex vivo liver resection and autotransplantation represent an alternative curative treatment option.
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Affiliation(s)
- Yu Zhang
- Organ Transplantation Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Ping Xie
- Organ Transplantation Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Chong Yang
- Organ Transplantation Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Hongji Yang
- Organ Transplantation Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Jun Liu
- Ultrasonography Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Guo Zhou
- Ultrasonography Department, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China
| | - Shaoping Deng
- Organ Transplantation Center, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan, China.
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong Special Administrative Region.
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27
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Yoon YI, Lee SG, Moon DB, Kim KH, Park CS, Park GC, Cho YP. Hypothermic perfusion hepatectomy for unresectable liver cancer: A single-center experience. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 27:254-264. [PMID: 31562749 DOI: 10.1002/jhbp.681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/20/2019] [Accepted: 09/25/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The resection of liver tumors that involve the hepatic veins adjacent to the vena cava or hepatic hilum is technically challenging. We present our surgical techniques and the long-term outcome of five patients with conventionally unresectable tumors. METHODS Five patients with conventionally unresectable tumors were successfully treated by "ex-situ liver resection" and "in-situ and ante-situm hypothermic liver perfusion" under total vascular exclusion and venovenous bypass. RESULTS These approaches allowed complete tumor removal with vascular reconstruction under a bloodless surgical field, while minimizing hepatic ischemic injury and preserving liver function. No perioperative mortalities occurred, and postoperative complications were minimal. The postoperative survival periods were limited due to the advanced malignancies in our patients, but the survival benefit was encouraging. The median postoperative survival time was 29.1 months, with the longest survival period being nearly 10 years. These approaches improved the quality of life and provided an opportunity for additional treatment. CONCLUSIONS Hypothermic perfusion hepatectomy is a realistic option for achieving surgical cure or significantly improved survival and quality of life in patients with tumors deemed unresectable using conventional normothermic hepatectomy. These approaches can overcome the limitations of the liver's restricted normothermic ischemia tolerance or inaccessible tumor locations.
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Affiliation(s)
- Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Outcomes of different surgical resection techniques for end-stage hepatic alveolar echinococcosis with inferior vena cava invasion. HPB (Oxford) 2019; 21:1219-1229. [PMID: 30782476 DOI: 10.1016/j.hpb.2018.10.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatic alveolar echinococcosis (HAE) lesions with inferior vena cava (IVC) invasion require combined resection of the liver and IVC. The outcomes of different surgical treatments, including in situ, ante situm and ex vivo resection, remain unclear. METHODS A total of 71 consecutive HAE patients who underwent hepatectomy with retrohepatic IVC resection were included. The patients were divided into ex vivo liver resection and autotransplantation (ERAT) group (n = 45) and in vivo resection group (n = 26). These techniques were assessed for feasibility and short- and long-term outcomes. RESULTS There were no significant differences with respect to postoperative complications and mortality between the ERAT and in vivo resection groups. The causes of mortality were liver failure in 3 patients, hemorrhagic shock in 1 patient, intra-abdominal bleeding in 1 patient, and acute cerebral hemorrhage in 1 patient. During a median of 22 months followed-up time, 2 patients developed ascites because of venous outflow stenosis, and 1 patient developed biliary stenosis in the ERAT group. The distant metastasis, local recurrence, and mortality rates were 0%, 1.4%, and 8.5%, respectively. CONCLUSION Combined liver resection and reconstruction of the IVC can be safely performed in selected patients with in situ, ante situm, and ex vivo resection.
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Navez J, Cauchy F, Dokmak S, Goumard C, Faivre E, Weiss E, Paugam C, Scatton O, Soubrane O. Complex liver resection under hepatic vascular exclusion and hypothermic perfusion with versus without veno-venous bypass: a comparative study. HPB (Oxford) 2019; 21:1131-1138. [PMID: 30723061 DOI: 10.1016/j.hpb.2018.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/14/2018] [Accepted: 12/28/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND While hypothermic liver perfusion has been shown to improve parenchymal tolerance to complex resections in patients requiring prolonged hepatic vascular exclusion (HVE), the benefit of associated veno-venous bypass (VVB) in this setting remains poorly evaluated. METHODS All patients undergoing liver resection requiring HVE and hypothermic liver perfusion for at least 55 min between 2006 and 2017 were retrospectively reviewed. Perioperative outcomes were compared between patients with (VVB+) or without VVB (VVB-). RESULTS Twenty-seven patients were analyzed, including 13 VVB+ and 14 VVB-. Median HVE duration was similar in VVB+ and VVB- patients (96 vs. 75 min, respectively). VVB+patients had longer operative time (460 vs. 375 min, p = 0.023) but less blood loss (p = 0.010). Five (19%) patients died postoperatively from liver failure or sepsis, without difference between groups. Postoperative major morbidity rate was similar between VVB+ and VVB- patients (30% vs. 50%, respectively) such as rates of liver failure, haemorrhage, renal insufficiency and sepsis, but VVB- patients experienced more respiratory complications (64% vs. 15%, p = 0.012). CONCLUSION During liver resection under HVE and hypothermic liver perfusion, use of VVB allows for reducing blood loss and postoperative respiratory complications. VVB should be recommended in case of liver resection with prolonged HVE.
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Affiliation(s)
- Julie Navez
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplant, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France(4)
| | - François Cauchy
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplant, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France(4)
| | - Safi Dokmak
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplant, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France(4)
| | - Claire Goumard
- Department of Hepatobiliary Surgery and Liver transplantation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, 75013, Paris, France(5)
| | - Evelyne Faivre
- Department of Anesthesiology and Critical Care, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France(4)
| | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France(4)
| | - Catherine Paugam
- Department of Anesthesiology and Critical Care, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France(4)
| | - Olivier Scatton
- Department of Hepatobiliary Surgery and Liver transplantation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, 75013, Paris, France(5)
| | - Olivier Soubrane
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplant, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France(4).
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Efanov MG, Alikhanov RB, Vishnevsky VA. Transplantation techniques in surgery for locally advanced liver tumors (review). ANNALY KHIRURGICHESKOY GEPATOLOGII = ANNALS OF HPB SURGERY 2019; 23:11-20. [DOI: 10.16931/1995-5464.2018411-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2025]
Affiliation(s)
- M. G. Efanov
- Loginov Moscow Clinical Scientific Center, Moscow Healthcare Department
| | - R. B. Alikhanov
- Loginov Moscow Clinical Scientific Center, Moscow Healthcare Department
| | - V. A. Vishnevsky
- Vishnevsky National Medical Research Center for Surgery, Healthcare Ministry of Russia
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Baimas‐George MR, Levi DM, Eskind LB, Kirks RC, Passeri M, Lessne M, Kardassis D, Salmon S, Iannitti DA, Vrochides D. Ex vivo liver resection coupled with associated liver partition and portal vein ligation: Combining existing techniques to achieve surgical resectability. J Surg Oncol 2019; 119:771-776. [DOI: 10.1002/jso.25375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 12/30/2018] [Indexed: 01/10/2023]
Affiliation(s)
| | - David M. Levi
- Division of Transplant SurgeryAtrium HealthCharlotte North Carolina
| | - Lon B. Eskind
- Division of Transplant SurgeryAtrium HealthCharlotte North Carolina
| | - Russell C. Kirks
- Division of Hepatobiliary and Pancreatic SurgeryAtrium HealthCharlotte North Carolina
| | - Michael Passeri
- Division of Hepatobiliary and Pancreatic SurgeryAtrium HealthCharlotte North Carolina
| | - Mark Lessne
- Division of Interventional RadiologyAtrium HealthCharlotte North Carolina
| | - Dimitrios Kardassis
- Division of Hepatobiliary and Pancreatic SurgeryAtrium HealthCharlotte North Carolina
| | - Stuart Salmon
- Division of Hematology and Oncology, Levine Cancer Institute Carolinas Medical Center, Atrium HealthCharlotte North Carolina
| | - David A. Iannitti
- Division of Hepatobiliary and Pancreatic SurgeryAtrium HealthCharlotte North Carolina
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic SurgeryAtrium HealthCharlotte North Carolina
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Ozsoy M, Ozsoy Z, Yilmaz S, Arikan Y. Ex situ Liver Resection and Partial Liver Autotransplantation for Advanced Cholangiocarcinoma. Niger J Surg 2019; 25:97-100. [PMID: 31007521 PMCID: PMC6452762 DOI: 10.4103/njs.njs_4_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Surgery is the only known curative treatment option for cholangiocarcinoma. Ex situ liver surgery and autotransplantation are promising approaches in cases that cannot be treated by conventional methods and particularly in the presence of centrally localized liver tumors as well as tumors that invade the main vascular structures. A 53-year-old female patient presented with abdominal pain and nausea. Abdominal tomography showed a tumoral mass lesion that filled the left lobe of the liver and invaded the left hepatic vein and the inferior vena cava. Cholangiocarcinoma diagnosis was reached based on biopsy findings, and the patient was scheduled for surgery as positron emission tomography did not indicate any other disease focus. The patient underwent ex situ liver resection and autotransplantation. She was discharged on the 7th postoperative day. A 68-year-old male presented with abdominal pain, weakness, and weight loss. Laboratory analysis indicated elevated carbohydrate antigen 19-9: 400 U/ml and alpha-fetoprotein (AFP): 2000 U/ml, and there was no other pathology. Abdominal tomography showed a mass that filled the center of the liver and invaded the left hepatic vein and the inferior vena cava. Pathological findings of the biopsy sample were reported as combined hepatocellular-cholangiocellular carcinoma. The patient's AFP levels continued to increase despite transcatheter arterial chemoembolization and radiofrequency ablation therapy. Surgery was decided as indocyanine green clearance test, and the result was 8.5%. He underwent ex situ liver resection and autotransplantation. Unfortunately, he died on the 4th postoperative day due to respiratory failure. Ex vivo liver resection and partial liver autotransplantation should be considered for the surgical treatment of locally advanced cholangiocarcinomas that invaded the main vascular structures.
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Affiliation(s)
- Mustafa Ozsoy
- Department of General Surgery, Parkhayat Hospital, Afyon, Turkey
| | - Zehra Ozsoy
- Department of Internal Medicine, State Hospital, Afyon, Turkey
| | - Sezgin Yilmaz
- Department of General Surgery, Faculty of Medicine, Afyon Kocatepe University, Afyon, Turkey
| | - Yüksel Arikan
- Department of General Surgery, Faculty of Medicine, Afyon Kocatepe University, Afyon, Turkey
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Hwang R, Liou P, Kato T. Ex vivo liver resection and autotransplantation: An emerging option in selected indications. J Hepatol 2018; 69:1002-1003. [PMID: 30243765 DOI: 10.1016/j.jhep.2018.09.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/07/2018] [Accepted: 09/07/2018] [Indexed: 12/04/2022]
Affiliation(s)
- Regina Hwang
- Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York, United States
| | - Peter Liou
- Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York, United States
| | - Tomoaki Kato
- Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York, United States.
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Ex vivo liver resection and autotransplantation as alternative to allotransplantation for end-stage hepatic alveolar echinococcosis. J Hepatol 2018; 69:1037-1046. [PMID: 30031886 DOI: 10.1016/j.jhep.2018.07.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/02/2018] [Accepted: 07/09/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Radical resection is the best treatment for patients with advanced hepatic alveolar echinococcosis (AE). Liver transplantation is considered for selected advanced cases; however, a shortage of organ donors and the risk of postoperative recurrence are major challenges. The aim of this study was to assess the clinical outcomes of ex vivo liver resection and autotransplantation for end-stage AE. METHODS In this prospective study, 69 consecutive patients with end-stage hepatic AE were treated with ex vivo resection and liver autotransplantation between January 2010 and February 2017. The feasibility, safety and long-term clinical outcome of this technique were assessed. RESULTS Ex vivo extended hepatectomy with autotransplantation was successful in all patients without intraoperative mortality. The median weight of the graft and AE lesion were 850 (370-1,600) g and 1,650 (375-5,000) g, respectively. The median duration of the operation and anhepatic phase were 15.9 (8-24) h and 360 (104-879) min, respectively. Six patients did not need any blood transfusion. Complications higher than IIIa according to Clavien classification were observed in 10 patients. The 30-day-mortality and overall mortality (>90 days) were 7.24% (5/69) and 11.5% (8/69), respectively. The mean hospital stay was 34.5 (12-128) days. Patients were followed-up systematically for a median of 22.5 months (14-89) without recurrence. CONCLUSION This is the largest series assessing ex vivo liver resection and autotransplantation in end-stage hepatic AE. This technique could be an effective alternative to liver transplantation in patients with end-stage hepatic AE, with the advantage that it does not require an organ nor immunosuppressive agents. LAY SUMMARY Ex vivo liver resection and autotransplantation were performed in a large series of patients with end-stage hepatic alveolar echinococcosis. The results showed that this surgical option was feasible, with acceptable postoperative mortality, but 100% disease-free survival in survivors. Careful patient selection, as well as precise assessment for size and quality of the remnant liver are key to successful surgery.
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Shi SJ, Wang DL, Hu W, Peng F, Kang Q. Ex vivo liver resection and autotransplantation with cardiopulmonary bypass for hepatoblastoma in children: A case report. Pediatr Transplant 2018; 22:e13268. [PMID: 30003622 DOI: 10.1111/petr.13268] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
Abstract
Some primary and secondary liver carcinomas cannot be resected using a conventional approach due to their size, location, or major vascular invasion. The aim of this study was to explore the application of ex vivo liver resection and autotransplantation for complicated HB in children. A 1.5-year-old girl with HB after repeated chemotherapy was analyzed. In this patient, tumor invasion includes the IV, V, and VIII liver segments, and thrombosis formed in the inferior vena cava and right atrium. It is difficult to obtain complete tumor resection using conventional hepatectomy. The patient was treated via ex vivo liver resection and autotransplantation, and tumor thrombus in the inferior vena cava and right atrium was removed via cardiopulmonary bypass. Operative methods and precautions were analyzed during and after the operation. The operation was completed successfully within 8 hours, and the liver's cold ischemia time was 190 minutes. The patient recuperated successfully, and the liver's function and AFP levels gradually tended to normalize 2 weeks after the operation. Ultrasonic examination revealed that the blood flow velocity of the hepatic vein, portal vein, and hepatic artery was good. The patient recovered and was discharged 3 weeks after the operation. Ex vivo liver resection and autotransplantation have great application value for complicated HB in children that is not suitable for conventional hepatic lobectomy.
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Affiliation(s)
- Shu-Jun Shi
- Department of Hepatobiliary Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Deng-Liang Wang
- Department of Hepatobiliary Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Hu
- Department of Hepatobiliary Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Fei Peng
- Department of Hepatobiliary Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Quan Kang
- Department of Hepatobiliary Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Engineering Research Center of Stem Cell Therapy, China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing, China
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36
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Yang X, Qiu Y, Huang B, Wang W, Shen S, Feng X, Wei Y, Lei J, Zhao J, Li B, Wen T, Yan L. Novel techniques and preliminary results of ex vivo liver resection and autotransplantation for end-stage hepatic alveolar echinococcosis: A study of 31 cases. Am J Transplant 2018; 18:1668-1679. [PMID: 29232038 PMCID: PMC6055796 DOI: 10.1111/ajt.14621] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/09/2017] [Accepted: 12/03/2017] [Indexed: 02/05/2023]
Abstract
Ex vivo liver resection combined with autotransplantation is a recently introduced approach to cure end-stage hepatic alveolar echinococcosis (HAE), which is considered unresectable by conventional radical resection due to echinococcal dissemination into the crucial intrahepatic conduits and adjacent structures. This article aims discuss the manipulation details and propose reasonable indications for this promising technique. All patients successfully underwent liver autotransplantation with no intraoperative mortality. The median weight of the autografts was 636 g (360-1300 g), the median operation time was 12.5 hours (9.4-19.5 hours), and the median anhepatic phase was 309 minutes (180- 460 minutes). Intraoperative blood loss averaged 1800 mL (1200-6000 mL). Postoperative complications occurred in 13 patients during hospitalization; 5 patients experienced postoperative complications classified as Clavien-Dindo grade III or higher, and 2 patients died of intraabdominal bleeding and acute cerebral hemorrhage, respectively. Twenty-nine patients were followed for a median of 14.0 months (3-42 months), and no HAE recurrence was detected. The technique requires neither an organ donor nor any postoperative immunosuppressant, and the success of the treatment relies on meticulous preoperative assessments and precise surgical manipulation.
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Affiliation(s)
- Xianwei Yang
- Department of Liver Surgery & Liver Transplantation CenterWest China Hospital of Sichuan UniversityChengduChina
| | - Yiwen Qiu
- Department of Liver Surgery & Liver Transplantation CenterWest China Hospital of Sichuan UniversityChengduChina
| | - Bin Huang
- Department of Vascular SurgeryWest China Hospital of Sichuan UniversityChengduChina
| | - Wentao Wang
- Department of Liver Surgery & Liver Transplantation CenterWest China Hospital of Sichuan UniversityChengduChina
| | - Shu Shen
- Department of Liver Surgery & Liver Transplantation CenterWest China Hospital of Sichuan UniversityChengduChina
| | - Xi Feng
- Department of Liver Surgery & Liver Transplantation CenterWest China Hospital of Sichuan UniversityChengduChina
| | - Yonggang Wei
- Department of Liver Surgery & Liver Transplantation CenterWest China Hospital of Sichuan UniversityChengduChina
| | - Jianyong Lei
- Department of General SurgeryWest China Hospital of Sichuan UniversityChengduChina
| | - Jichun Zhao
- Department of Vascular SurgeryWest China Hospital of Sichuan UniversityChengduChina
| | - Bo Li
- Department of Liver Surgery & Liver Transplantation CenterWest China Hospital of Sichuan UniversityChengduChina
| | - Tianfu Wen
- Department of Liver Surgery & Liver Transplantation CenterWest China Hospital of Sichuan UniversityChengduChina
| | - Lunan Yan
- Department of Liver Surgery & Liver Transplantation CenterWest China Hospital of Sichuan UniversityChengduChina
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Tomimaru Y, Eguchi H, Wada H, Doki Y, Mori M, Nagano H. Liver resection combined with inferior vena cava resection and reconstruction using artificial vascular graft: A literature review. Ann Gastroenterol Surg 2018; 2:182-186. [PMID: 29863183 PMCID: PMC5980586 DOI: 10.1002/ags3.12068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/09/2018] [Indexed: 11/10/2022] Open
Abstract
In cases where liver tumors invade the inferior vena cava (IVC), IVC resection along with liver resection may be needed to effect a cure. Furthermore, if the IVC defect is large, IVC reconstruction with vascular graft after resection is required. There are limited reports of cases of IVC reconstruction using a graft. By reviewing data from the literature of previous studies, the present study was aimed at investigating the surgical outcomes of liver resection with IVC resection and reconstruction using an artificial vascular graft. PubMed was searched for previous articles reporting cases with the combined surgery. The search was limited to articles in English, and cases with exceptional surgeries such as in situ cold perfusion, and ante situm and ex vivo techniques were excluded from this study. Surgical outcomes of the extracted cases were investigated. Cases dealt only with primary closure after IVC resection, and those in which the IVC tumor thrombus was treated by opening the IVC wall, removing the thrombus and then closing the IVC without wall excision were not included in this study. The literature search identified 13 studies, including 111 cases. Operative mortality in the reported cases was 8.1% (9 out of 111 cases). Thrombus in the artificial vascular graft was observed in two cases, and patency of the graft during the follow-up period was confirmed in 109 of the 111 cases (98.2%). These results suggested that the surgical outcomes of liver resection combined with IVC resection and reconstruction using the artificial vascular graft were favorable.
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Affiliation(s)
- Yoshito Tomimaru
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuitaJapan
- Department of Gastroenterological SurgeryToyonaka Municipal HospitalToyonakaJapan
| | - Hidetoshi Eguchi
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuitaJapan
| | - Hiroshi Wada
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuitaJapan
- Department of Gastroenterological SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Yuichiro Doki
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuitaJapan
| | - Masaki Mori
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuitaJapan
| | - Hiroaki Nagano
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuitaJapan
- Department of Gastroenterological, Breast and Endocrine SurgeryYamaguchi University Graduate School of MedicineUbeJapan
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Augmented reality technology for preoperative planning and intraoperative navigation during hepatobiliary surgery: A review of current methods. Hepatobiliary Pancreat Dis Int 2018; 17:101-112. [PMID: 29567047 DOI: 10.1016/j.hbpd.2018.02.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 11/16/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Augmented reality (AR) technology is used to reconstruct three-dimensional (3D) images of hepatic and biliary structures from computed tomography and magnetic resonance imaging data, and to superimpose the virtual images onto a view of the surgical field. In liver surgery, these superimposed virtual images help the surgeon to visualize intrahepatic structures and therefore, to operate precisely and to improve clinical outcomes. DATA SOURCES The keywords "augmented reality", "liver", "laparoscopic" and "hepatectomy" were used for searching publications in the PubMed database. The primary source of literatures was from peer-reviewed journals up to December 2016. Additional articles were identified by manual search of references found in the key articles. RESULTS In general, AR technology mainly includes 3D reconstruction, display, registration as well as tracking techniques and has recently been adopted gradually for liver surgeries including laparoscopy and laparotomy with video-based AR assisted laparoscopic resection as the main technical application. By applying AR technology, blood vessels and tumor structures in the liver can be displayed during surgery, which permits precise navigation during complex surgical procedures. Liver transformation and registration errors during surgery were the main factors that limit the application of AR technology. CONCLUSIONS With recent advances, AR technologies have the potential to improve hepatobiliary surgical procedures. However, additional clinical studies will be required to evaluate AR as a tool for reducing postoperative morbidity and mortality and for the improvement of long-term clinical outcomes. Future research is needed in the fusion of multiple imaging modalities, improving biomechanical liver modeling, and enhancing image data processing and tracking technologies to increase the accuracy of current AR methods.
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Ye Q, Zeng C, Wang Y, Ming Y, Wan Q, Ye S, Xiong Y, Li L. Long-Term Outcomes of Ante-Situm Resection and Auto-Transplantation in Conventionally Unresectable Hepatocellular Carcinoma: A Single-Center Experience. Ann Transplant 2018; 23:81-88. [PMID: 29379006 PMCID: PMC6248319 DOI: 10.12659/aot.905983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Ante-situm resection and auto-transplantation (ante-situm for short) provides a more aggressive approach to conventionally unresectable hepatocellular carcinoma (HCC). We described the long-term outcomes of patients with HCCs who underwent this technique. Material/Methods Between October 2005 and December 2016, we performed 23 ante-situm liver resections. We evaluated postoperative complications, 90-day mortality, recurrence, and long-term survival rates, and reviewed the literature on this topic. Results Five types of complications associated with six patients were observed.: 1) primary nonfunctioning liver, thus receiving a liver transplantation; 2) initial poor liver function with recovery two weeks after treatment; 3) diagnoses of portal vein tumor thrombosis, biliary fistula, and small-for-size syndrome, respectively. The median follow-up was 3.6 years; 12 out of 23 patients were alive at the end of the study. One patient who had hepatic recurrence was lost to follow-up after three months. One patient died of multiple organ dysfunction syndrome after the operation, nine patients died due to hepatic recurrence and/or extrahepatic metastasis of HCC. The one-year, three-year, five-year, and 10-year survival rates were 65.2%, 56.5%, 50.9%, and 20.3%, respectively. The one-year, three-year, five-year, and 10-year recurrence rates were 60.9%, 50.7%, 50.7%, and 50.7%, respectively. The chi-square test revealed the patients with recurrence after ante-situm technique were more likely to have poor prognosis (mortality of patients with recurrence versus no-recurrence: 88.9% versus 14.3%, p<0.05) and a strong association was evidenced by Cramer’s V statistic (Cramer’s V=0.734). Conclusions Ante-situm procedure showed benefits in select patients with HCCs who had contraindications for conventional resection operations. In our case series, the ante-situm technique resulted in lower mortality compared to other ex-vivo hepatic resection techniques reported in the literature and similar long-term efficacy compared to cases of HCCs suitable for conventional resections. HCCs recurrence was a major risk factor associated with the survival rate of ante-situm technique.
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Affiliation(s)
- Qifa Ye
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland).,The 3rd Xiangya Hospital of Central South University, Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, Hunan, China (mainland)
| | - Cheng Zeng
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Yanfeng Wang
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Yingzi Ming
- The 3rd Xiangya Hospital of Central South University, Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, Hunan, China (mainland)
| | - Qiquan Wan
- The 3rd Xiangya Hospital of Central South University, Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, Hunan, China (mainland)
| | - Shaojun Ye
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Yan Xiong
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Ling Li
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
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40
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Park JH, Jeon UB, Choo KS, Kim TU, Chu CW, Ryu JH. Percutaneous transhepatic hepatic venous stenting after extracorporeal hepatic resection and autotransplantation: A case report. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jung Hwan Park
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ung Bae Jeon
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ki Seok Choo
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Tae Un Kim
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Chong Woo Chu
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Je Ho Ryu
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
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41
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Yamamoto M, Akamatsu N, Hayashi A, Togashi J, Sakamoto Y, Tamura S, Hasegawa K, Fukayama M, Makuuchi M, Kokudo N. Safety and efficacy of venous reconstruction in liver resection using cryopreserved homologous veins. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:511-519. [PMID: 28660678 DOI: 10.1002/jhbp.488] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Only a few studies have reported the resection and reconstruction of major hepatic veins during hepatectomy. Here, we present our strategy and techniques for venous reconstruction with cryopreserved homologous veins, and describe the surgical outcome. METHODS Among 2,387 hepatectomy patients, 39 patients who required hepatic venous reconstruction were reviewed retrospectively. Venous reconstruction was performed to secure a non-congested liver remnant volume of at least 40% of the total liver volume. RESULTS There was no operative mortality, and the severe morbidity rate was 5% in this series. A total of 41 veins were reconstructed; 30 with homologous veins (73.2%) and 11 with autologous veins (26.8%), with the middle hepatic vein being the most frequent (n = 23, 56%). Interposition grafting was performed more often (P = 0.003), the length of the venous resection was longer (P = 0.007), and pathologic wall infiltration of the vein was revealed more often (P = 0.002) in the homologous graft group than in the autologous graft group. The 1-, 2-, and 3-year overall patency of the reconstructed veins was 55.4%, 46.3%, and 46.3%, respectively. CONCLUSIONS Aggressive venous reconstruction during hepatectomy using cryopreserved homologous veins is a feasible option with satisfactory short-term outcomes, and may be warranted to improve operative safety.
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Affiliation(s)
- Masaki Yamamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Akimasa Hayashi
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Togashi
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Sumihito Tamura
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Masashi Fukayama
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Masatoshi Makuuchi
- Division of Hepato-Billiary-Pancreatic Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Abstract
Most abdominal neoplasms involving the root of the superior mesenteric artery and/or celiac artery are difficult to manage with conventional operative techniques because of limited intestinal ischemia times and poor accessibility to the tumor region. Ex vivo surgery followed by intestinal autotransplantation (IATx) is a relatively novel surgical strategy to offer chances for complete resection in such hopeless circumstances. This review aims to assess potential surgical indications, operative techniques and clinical outcomes after IATx. Currently the main indications reported for IATx broadly include pancreatic, mesenteric and retroperitoneal neoplasms closely involving the superior mesenteric vessels. The preliminary results show that radical resection can be effectively achieved in carefully selective patients. Although perioperative morbidity and mortality are relatively high, there are several long-term survivors, particularly after complete resection of benign and low-grade tumor. Early tumor recurrence, however, remains a major problem in patients with high-grade tumor, particularly pancreatic ductal carcinoma. In conclusion, IATx allows patients with selected abdominal neoplasms involving the major mesenteric vessels to be completely resected. However, this aggressive approach is associated with a considerable operative risk, and should only be performed at experienced centers. Additional and adjunctive treatment therapies are required to improve the efficacy of this treatment.
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Affiliation(s)
- Guosheng Wu
- Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
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Angelico R, Passariello A, Pilato M, Cozzolino T, Piazza M, Miraglia R, D'Angelo P, Capasso M, Saffioti MC, Alberti D, Spada M. Ante situm liver resection with inferior vena cava replacement under hypothermic cardiopolmunary bypass for hepatoblastoma: Report of a case and review of the literature. Int J Surg Case Rep 2017. [PMID: 28651228 PMCID: PMC5485760 DOI: 10.1016/j.ijscr.2017.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Hepatoblastoma with tumour thrombi extending into inferior-vena-cava and right atrium are often unresectable with an extremely poor prognosis. The surgical approach is technically challenging and might require major liver resection with vascular reconstruction and extracorporeal circulation. However, which is the best surgical technique is yet unclear. PRESENTATION OF CASE A 11-months-old boy was referred for a right hepatic lobe mass(90×78mm) suspicious of hepatoblastoma with tumoral thrombi extending into the inferior-vena-cava and the right atrium, bilateral lung lesions and serum alpha-fetoprotein level of 50.795IU/mL. After 8 months of chemotherapy (SIOPEL 2004-high-risk-Protocol), the lung lesions were no longer clearly visible and the hepatoblastoma size decreased to 61×64mm. Thus, ante situm liver resection was planned: after hepatic parenchymal transection, hypothermic cardiopulmonary bypass was started and en bloc resection of the extended-right hepatic lobe, the retro/suprahepatic cava and the tumoral trombi was performed with concomitant cold perfusion of the remnant liver. The inferior-vena-cava was replaced with an aortic graft from a blood-group compatible cadaveric donor. The post-operative course was uneventful and after 8 months of follow-up the child has normal liver function and an alpha-fetoprotein level and is free of disease recurrence with patent vascular graft. CONCLUSIONS We report for the first time a case of ante situ liver resection and inferior-vena-cava replacement associated with hypothermic cardiopulmonary bypass in a child with hepatoblastoma. Herein, we extensively review the literature for hepatoblastoma with thumoral thrombi and we describe the technical aspects of ante situm approach, which is a realistic option in otherwise unresectable hepatoblastoma.
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Affiliation(s)
- Roberta Angelico
- Department of Abdominal Transplantation and Hepatobiliary and Pancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
| | - Annalisa Passariello
- Department of Translational Medical Science, University of Naples "Federico II", Naples, Italy; Department of Pediatric Oncology, Ospedale Santobono- Pausilipon, Naples, Italy.
| | - Michele Pilato
- Cardiac Surgery and Heart Transplantation Unit, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy.
| | - Tommaso Cozzolino
- Department of Translational Medical Science, University of Naples "Federico II", Naples, Italy.
| | - Marcello Piazza
- Department of Anesthesia and Intensive Care, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy.
| | - Roberto Miraglia
- Radiology Service, Department of Diagnostic and Therapeutic Services, IRCCS - ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy.
| | - Paolo D'Angelo
- "Giovanni Di Cristina" Children's Hospital, Pediatric Hematology and Oncology, Palermo, Italy.
| | - Mariella Capasso
- Department of Pediatric Oncology, Ospedale Santobono- Pausilipon, Naples, Italy.
| | - Maria Cristina Saffioti
- Department of Abdominal Transplantation and Hepatobiliary and Pancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
| | - Daniele Alberti
- Department of Pediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy.
| | - Marco Spada
- Department of Abdominal Transplantation and Hepatobiliary and Pancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
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Abstract
BACKGROUND With the recent advances in oncological hepatic surgery, major liver resections became more widely utilized procedures. The era of modern hepatic surgery witnessed improvements in patients care in preoperative, intraoperative and postoperative aspects. This significantly improved surgical outcomes regarding morbidity and mortality. This review article focuses on the recent advances in oncological hepatic surgery. DATA SOURCES This review includes only data from peer-reviewed articles and journals. PubMed database was utilized as the primary source of the supporting literature to this review article on the latest advances in oncological hepatic surgery. Comprehensive and high sensitivity search strategies were performed to search related studies exhaustively up till June 2016. We critically and independently assessed over 50 recent publications written on this topic according to the selection criteria and quality assessment standard. We paid particular attention to the studies published in high impact journals that address the use of the surgical techniques mentioned in the articles in well-known institutions. RESULTS Among all utilized approaches aiming at the preoperative assessment of the liver function, Child-Turcotte-Pugh classification remains the most reliable tool correlating with survival outcome. Although the primary radiological tools including ultrasonography, computed tomography and magnetic resonance imaging remain on top of the menu of tests utilized in assessment of focal hepatic lesions, intraoperative ultrasonography projects to be a powerful additional tool in terms of sensitivity and specificity compared to the other conventional techniques in assessment of the liver in the operative setting, a procedure that can change the surgical strategy in 27.2% of the cases and consequently improve the oncological surgical outcome. In addition to the conventional surgical techniques of liver resection and portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy "ALPPS" projects to be an alternative option in patients with marginally resectable tumors with an inadequate size of future liver remnant with an accepted surgical oncological outcome. CONCLUSIONS Considering the clinicopathological nature of hepatic lesions, the comprehensive assessment and proper choice of the liver resection technique in highly selected patients is associated with improved surgical oncological outcome. Patients with underlying marginal future liver remnant volumes can now safely benefit from a wider range of surgical intervention, a breakthrough that significantly improved morbidity and mortality in this group of patients.
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Affiliation(s)
- Ahmed I Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue BX7375 CLINICAL SCIENCE CNTR Madison, WI 53792-7375, USA.
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Ye QF, Senninger N. The consensus on liver autotransplantation from an international panel of experts. Hepatobiliary Pancreat Dis Int 2017; 16:10-16. [PMID: 28119253 DOI: 10.1016/s1499-3872(16)60175-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Qi-Fa Ye
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430071, China; Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, The 3rd Xiangya Hospital of Central South University, Changsha 410013, China.
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46
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Combined in situ hypothermic liver preservation and cardioplegia for resection of hepatoblastoma with intra-atrial extension in a 3 year old child. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2016. [DOI: 10.1016/j.epsc.2016.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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47
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Wu G, Zhao Q, Wang W, Shi H, Wang M, Zhang J, Li Z, Fan D. Clinical and nutritional outcomes after intestinal autotransplantation. Surgery 2016; 159:1668-1676. [DOI: 10.1016/j.surg.2016.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/28/2015] [Accepted: 01/12/2016] [Indexed: 02/07/2023]
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48
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Kobayashi T, Miura K, Ishikawa H, Soma D, Zhang Z, Yuza K, Hirose Y, Takizawa K, Nagahashi M, Sakata J, Kameyama H, Kosugi S, Wakai T. Successful Re-resection for Locally Recurrent Retroperitoneal Liposarcoma at Four Years After Ex Vivo Tumor Resection and Autotransplantation of the Liver: A Case Report. Transplant Proc 2016; 48:1215-7. [PMID: 27320590 DOI: 10.1016/j.transproceed.2016.01.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 01/14/2016] [Indexed: 10/21/2022]
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49
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Liver transplantation for hepatobiliary malignancies: a new era of "Transplant Oncology" has begun. Surg Today 2016; 47:403-415. [PMID: 27130463 DOI: 10.1007/s00595-016-1337-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/06/2016] [Indexed: 01/10/2023]
Abstract
The indications of liver transplantation for hepatobiliary malignancies have been carefully expanded in a stepwise fashion, despite the fundamental limitations in oncological, immunological, and technical aspects. A new era of "Transplant Oncology," the fusion of transplant surgery and surgical oncology, has begun, and we stand at the dawn of a paradigm shift in multidisciplinary cancer treatment. For hepatocellular carcinoma, new strategies have been undertaken to select recipients based on biological and dynamic markers instead of conventional morphological and static parameters, opening the doors for a more deliberate expansion of the Milan criteria and locoregional therapies before liver transplantation. Neoadjuvant chemoradiation therapy followed by liver transplantation for unresectable perihilar cholangiocarcinoma developed by the Mayo Clinic provided excellent outcomes in a US multicenter study; however, the surgical indications are not necessarily universal and await international validation. Similarly, an aggressive multidisciplinary approach has been applied for other tumors, including intrahepatic cholangiocarcinoma, hepatoblastoma, liver metastases from colorectal and neuroendocrine primary and gastrointestinal stromal tumors as well as rare tumors, such as hepatic undifferentiated embryonal sarcoma and infantile choriocarcinoma. In conclusion, liver transplantation is an important option for hepatobiliary malignancies; however, prospective studies are urgently needed to ensure the appropriate patient selection, organ allocation and living donation policies, and administration of antineoplastic immunosuppression.
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50
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Wen H, Dong JH, Zhang JH, Duan WD, Zhao JM, Liang YR, Shao YM, Ji XW, Tai QW, Li T, Gu H, Tuxun T, He YB, Huang JF. Ex Vivo Liver Resection and Autotransplantation for End-Stage Alveolar Echinococcosis: A Case Series. Am J Transplant 2016; 16:615-24. [PMID: 26460900 DOI: 10.1111/ajt.13465] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/12/2015] [Accepted: 07/14/2015] [Indexed: 01/25/2023]
Abstract
The role of autotransplantation in end-stage hepatic alveolar echinococcosis (AE) is unclear. We aimed to present our 15-case experience and propose selection criteria for autotransplantation. All patients were considered to have unresectable hepatic AE by conventional resection due to critical invasion to retrohepatic vena cava, hepatocaval region along with three hepatic veins, and the tertiary portal and arterial branches. All patients successfully underwent ex vivo extended right hepatectomy and autotransplantation without intraoperative mortality. The median autograft weight was 706 g (380-1000 g); operative time was 15.5 hours (11.5-20.5 hours); and anhepatic time was 283.8 minutes (180-435 min). Postoperative hospital stay was 32.3 days (12-60 days). Postoperative complication Clavien-Dindo grade IIIa or higher occurred in three patients including one death that occurred 12 days after the surgery due to acute liver failure. One patient was lost to follow-up after the sixth month. Thirteen patients were followed for a median of 21.6 months with no relapse. This is the largest reported series of patients with end-stage hepatic AE treated with liver autotransplantation. The technique requires neither organ donor nor postoperative immunosuppressant. The early postoperative mortality was low with acceptable morbidity. Preoperative precise assessment and strict patient selection are of utmost importance.
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Affiliation(s)
- H Wen
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - J-H Dong
- Department of Hepatobiliary Surgery, Beijing Tsinghua Chang Gung Hospital, Beijing, P.R. China
| | - J-H Zhang
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - W-D Duan
- Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, P.R. China
| | - J-M Zhao
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - Y-R Liang
- Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, P.R. China
| | - Y-M Shao
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - X-W Ji
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - Q-W Tai
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - T Li
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - H Gu
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - T Tuxun
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - Y-B He
- Department of Liver and Laparoscopic Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uyghur Autonomous Region, P.R. China
| | - J-F Huang
- Department of Hepatobiliary Surgery, Peking Union Medical College Hospital, Beijing, P.R. China
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