Ex Vivo Liver Resection and Autotransplantation: Should It be Used More Frequently?
Journal
Annals of surgery
ISSN: 1528-1140
Titre abrégé: Ann Surg
Pays: United States
ID NLM: 0372354
Informations de publication
Date de publication:
01 11 2022
01 11 2022
Historique:
received:
15
02
2022
accepted:
11
06
2022
pubmed:
4
8
2022
medline:
12
10
2022
entrez:
3
8
2022
Statut:
ppublish
Résumé
We herein advocate for more extensive utilization of ex vivo resection techniques for otherwise unresectable liver tumors by presenting the largest collective American experience. Advanced in situ resection and vascular reconstruction techniques have made R0 resection possible for otherwise unresectable liver tumors. Ex vivo liver resection may further expand the limits of resectability but remains underutilized due to concerns about technical complexity and vascular thrombosis. However, we believe that the skillset required for ex vivo liver resection is more widespread and the complications less severe than widely assumed, making ex vivo resection a more attractive option in selected case. We retrospectively analyzed 35 cases performed by surgical teams experienced with ex vivo liver resections (at least 4 cases) between 1997 and 2021. We categorized malignancies as highly aggressive (n=18), moderately aggressive (n=14), and low grade (n=3). All patients underwent total hepatectomy, vascular reconstruction and resection in hypothermia on the backtable, and partial liver autotransplantation. Overall survival was 67%/39%/28%, at 1/3/5 years, respectively, with a median survival of 710 days (range: 22-4824). Patient survival for highly aggressive, moderately aggressive, and low-grade tumors was 61%/33%/23%, 67%/40%/22%, and 100%/100%/100% at 1/3/5 years, respectively, with median survival 577 days (range: 22-3873), 444 days (range: 22-4824), and 1825 days (range: 868-3549). Ex vivo resection utilizes techniques commonly practiced in partial liver transplantation, and we demonstrate relatively favorable outcomes in our large collective experience. Therefore, we propose that more liberal use of this technique may benefit selected patients in centers experienced with partial liver transplantation.
Sections du résumé
OBJECTIVE
We herein advocate for more extensive utilization of ex vivo resection techniques for otherwise unresectable liver tumors by presenting the largest collective American experience.
BACKGROUND
Advanced in situ resection and vascular reconstruction techniques have made R0 resection possible for otherwise unresectable liver tumors. Ex vivo liver resection may further expand the limits of resectability but remains underutilized due to concerns about technical complexity and vascular thrombosis. However, we believe that the skillset required for ex vivo liver resection is more widespread and the complications less severe than widely assumed, making ex vivo resection a more attractive option in selected case.
METHODS
We retrospectively analyzed 35 cases performed by surgical teams experienced with ex vivo liver resections (at least 4 cases) between 1997 and 2021.
RESULTS
We categorized malignancies as highly aggressive (n=18), moderately aggressive (n=14), and low grade (n=3). All patients underwent total hepatectomy, vascular reconstruction and resection in hypothermia on the backtable, and partial liver autotransplantation. Overall survival was 67%/39%/28%, at 1/3/5 years, respectively, with a median survival of 710 days (range: 22-4824). Patient survival for highly aggressive, moderately aggressive, and low-grade tumors was 61%/33%/23%, 67%/40%/22%, and 100%/100%/100% at 1/3/5 years, respectively, with median survival 577 days (range: 22-3873), 444 days (range: 22-4824), and 1825 days (range: 868-3549).
CONCLUSIONS
Ex vivo resection utilizes techniques commonly practiced in partial liver transplantation, and we demonstrate relatively favorable outcomes in our large collective experience. Therefore, we propose that more liberal use of this technique may benefit selected patients in centers experienced with partial liver transplantation.
Identifiants
pubmed: 35920562
doi: 10.1097/SLA.0000000000005640
pii: 00000658-202211000-00016
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
854-859Informations de copyright
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
The authors report no conflicts of interest.
Références
Demir IE, Jager C, Schlitter AM, et al. R0 versus R1 resection matters after pancreaticoduodenectomy, and less after distal or total pancreatectomy for pancreatic cancer. Ann Surg. 2018;268:1058–1068.
Mann GN, Mann LV, Levine EA, et al. Primary leiomyosarcoma of the inferior vena cava: a 2-institution analysis of outcomes. Surgery. 2012;151:261–267.
Spolverato G, Yakoob MY, Kim Y, et al. The impact of surgical margin status on long-term outcome after resection for intrahepatic cholangiocarcinoma. Ann Surg Oncol. 2015;22:4020–4028.
Tan MC, Brennan MF, Kuk D, et al. Histology-based classification predicts pattern of recurrence and improves risk stratification in primary retroperitoneal sarcoma. Ann Surg. 2016;263:593–600.
Wagner M, Redaelli C, Lietz M, et al. Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma. Br J Surg. 2004;91:586–594.
Schlegel A, Sakuraoka Y, Motwani K, et al. 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.
Oldhafer KJ, Stavrou GA, Wagner KC, et al. Liver resection with in situ hypothermic perfusion: an old but effective method. Ann Surg Oncol. 2019;26:1859.
Oldhafer KJ, Wagner KC, Kantas A, et al. Hybrid-ALPPS followed by ante situm with cardiopulmonary bypass: rapid liver augmentation and complex surgery. Ann Surg Oncol. 2020;27:3341.
Dubay D, Gallinger S, Hawryluck L, et al. In situ hypothermic liver preservation during radical liver resection with major vascular reconstruction. Br J Surg. 2009;96:1429–1436.
Hannoun L, Balladur P, Delva E, et al. “Ex situ-in vivo” surgery of the liver: a new technique in liver surgery. Principles and preliminary results. Gastroenterol Clin Biol. 1991;15:758–761.
Moris D, Tsilimigras DI, Chakedis J, et al. Liver transplantation for unresectable colorectal liver metastases: a systematic review. J Surg Oncol. 2017;116:288–297.
Otte JB, de Ville de Goyet J, Reding R. Liver transplantation for hepatoblastoma: indications and contraindications in the modern era. Pediatr Transplant. 2005;9:557–565.
Meyers RL, Tiao GM, Dunn SP, et al. Liver transplantation in the management of unresectable hepatoblastoma in children. Front Biosci (Elite Ed). 2012;4:1293–1302.
Kato T, Hwang R, Liou P, et al. Ex vivo resection and autotransplantation for conventionally unresectable tumors—an 11-year single center experience. Ann Surg. 2020;272:766–772.
Pichlmayr R, Bretschneider HJ, Kirchner E, et al. Ex situ operation on the liver. A new possibility in liver surgery. Langenbecks Arch Chir. 1988;373:122–126.
Wen H, Dong JH, Zhang JH, et al. Ex vivo liver resection and autotransplantation for end-stage alveolar echinococcosis: a case series. Am J Transplant. 2016;16:615–624.
Yang X, Qiu Y, Huang B, et al. 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.
Aji T, Dong JH, Shao YM, et al. Ex vivo liver resection and autotransplantation as alternative to allotransplantation for end-stage hepatic alveolar echinococcosis. J Hepatol. 2018;69:1037–1046.
Boggi U, Vistoli F, Del Chiaro M, et al. Extracorporeal repair and liver autotransplantation after total avulsion of hepatic veins and retrohepatic inferior vena cava injury secondary to blunt abdominal trauma. J Trauma. 2006;60:405–406.
Hemming AW, Cattral MS. Ex vivo liver resection with replacement of the inferior vena cava and hepatic vein replacement by transposition of the portal vein. J Am Coll Surg. 1999;189:523–526.
Hemming AW, Chari RS, Cattral MS. Ex vivo liver resection. Can J Surg. 2000;43:222–224.
Hwang R, Liou P, Kato T. Ex vivo liver resection and autotransplantation: an emerging option in selected indications. J Hepatol. 2018;69:1002–1003.
Lechaux D, Megevand JM, Raoul JL, et al. Ex vivo right trisegmentectomy with reconstruction of inferior vena cava and “flop” reimplantation. J Am Coll Surg. 2002;194:842–845.
Raab R, Schlitt HJ, Oldhafer KJ, et al. Ex-vivo resection techniques in tissue-preserving surgery for liver malignancies. Langenbecks Arch Surg. 2000;385:179–184.
Yanaga K, Kishikawa K, Shimada M, et al. Extracorporeal hepatic resection for previously unresectable neoplasms. Surgery. 1993;113:637–643.
Kwong A, Kim WR, Lake JR, et al. OPTN/SRTR 2018 Annual Data Report: Liver. Am J Transplant. 2020;20(suppl s1):193–299.