Skip to main content
SpringerLink
Log in

Complex Hepatectomy Under Total Vascular Exclusion of the Liver Preserving the Caval Flow with Portal Hypothermic Perfusion and Temporary Portacaval Shunt: A Proof of Concept

  • Hepatobiliary Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Hypothermic liver perfusion decreases ischemia/reperfusion injury during hepatectomy under standard total vascular exclusion (TVE) of the liver. This surgery needs venovenous bypass and is hampered by high morbi-mortality. TVE preserving the inferior vena cava (IVC) flow is hemodynamically well tolerated but remains limited in duration when performed under liver normothermia. The objective of this study was to report the results of TVE preserving the caval flow, modified to allow hypothermic liver perfusion and obviate splanchnic congestion.

Patients and Methods

The technique, indicated for tumors abutting large tributaries of the hepatic veins but sparing their roots in IVC and the latter, was applied when TVE was anticipated to last for ≥ 60 min. It combines continuous TVE preserving the IVC flow with hypothermic liver perfusion and temporary portacaval shunt (PCS). Results are given as median (range).

Results

Vascular control was achieved in 13 patients with excellent hemodynamical tolerance. PCS was direct or via an interposed synthetic graft (five and eight cases, respectively). Liver temperature dropped to 16.5 (6–24) °C under perfusion of 2 (2–4) L of cold perfusate. TVE lasted 67 (54–125) min and 4.5 (0–8) blood units were transfused. Resection was major in nine cases and was complete in all cases. Five complications occurred in four patients, and the 90-day mortality rate was zero.

Conclusions

This technique maintains stable hemodynamics and combines the advantages of in situ or ex situ standard TVE with hypothermic liver perfusion, without their inherent prolongation of ischemia time and need for venovenous bypass.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Nagasue N, Yukaya H, Ogawa Y, et al. Segmental and subsegmental resections of the cirrhotic liver under hepatic inflow and outflow occlusion. Br J Surg. 1985;72:565–8.

    Article  CAS  PubMed  Google Scholar 

  2. Elias D, Lasser P, Debaene B, et al. Intermittent vascular exclusion of the liver (without vena cava clamping) during major hepatectomy. Br J Surg. 1995;82:1535–9.

    Article  CAS  PubMed  Google Scholar 

  3. Cherqui D, Malassagne B, Colau PI, et al. Hepatic vascular exclusion with preservation of the caval flow for liver resections. Ann Surg. 1999;230:24–30.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Belghiti J, Noun R, Zante E, et al. Portal triad clamping or hepatic vascular exclusion for major liver resection. A controlled study. Ann Surg. 1996;224:155–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Hoffmann K, Weigand MA, Hillebrand N, et al. Is veno-venous bypass still needed during liver transplantation? A review of the literature. Clin Transplant. 2009;23:1–8.

    Article  PubMed  Google Scholar 

  6. Huguet C, Nordlinger B, Galopin JJ, et al. Normothermic hepatic vascular exclusion for extensive hepatectomy. Surg Gynecol Obstet. 1978;147:689–93.

    CAS  PubMed  Google Scholar 

  7. Bismuth H, Castaing D, Garden OJ. Major hepatic resection under total vascular exclusion. Ann Surg. 1989;210:13–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Terblanche J, Krige JE, Bornman PC. Simplified hepatic resection with the use of prolonged vascular inflow occlusion. Arch Surg. 1991;126:298–301.

    Article  CAS  PubMed  Google Scholar 

  9. Huguet C, Gavelli A, Chieco PA, et al. Liver ischemia for hepatic resection: where is the limit? Surgery. 1992;111:251–9.

    CAS  PubMed  Google Scholar 

  10. Hannoun L, Borie D, Delva E, et al. Liver resection with normothermic ischaemia exceeding 1 h. Br J Surg. 1993;80:1161–5.

    Article  CAS  PubMed  Google Scholar 

  11. Emre S, Schwartz ME, Katz E, et al. Liver resection under total vascular isolation: variations on a theme. Ann Surg. 1993;217:15–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Habib N, Zografos G, Dalla Serra G, et al. Liver resection with total vascular exclusion for malignant tumours. Br J Surg. 1994;81:1181–4.

    Article  CAS  PubMed  Google Scholar 

  13. Emond JC, Kelley S, Heffron T, et al. Surgical and anesthetic management of patients undergoing total vascular isolation. Liver Transplant Surg. 1996;2:91–8.

    Article  CAS  Google Scholar 

  14. Evans P, Vogt DP, Mayes JT III, et al. Liver resection under total vascular exclusion. Surgery. 1998;124:807–15.

    Article  CAS  PubMed  Google Scholar 

  15. Berney T, Mentha G, Morel P. Total vascular exclusion of the liver for the resection of lesions in contact with the vena cava or the hepatic veins. Br J Surg. 1998;85:485–8.

    Article  CAS  PubMed  Google Scholar 

  16. Azoulay D, Eshkenazy R, Andreani P, et al. In situ hypothermic perfusion of the liver versus standard total vascular exclusion for complex liver resection. Ann Surg. 2005;241:277–85.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Navez J, Cauchy F, Dokmak S, et al. Complex liver resection under hepatic vascular exclusion and hypothermic perfusion with versus without veno-venous bypass: a comparative study. HPB (Oxford). 2019;21:1131–8.

    Article  PubMed  Google Scholar 

  18. Azoulay D, Maggi U, Lim C, et al. Liver resection using total vascular exclusion of the liver preserving the caval flow, in situ hypothermic portal perfusion and temporary porta-caval shunt: a new technique for central tumors. Hepatobiliary Surg Nutr. 2014;3:149–53.

    PubMed  PubMed Central  Google Scholar 

  19. Chen Y, Pu W, Maswikiti EP, et al. Intestinal congestion and reperfusion injury: damage caused to the intestinal tract and distal organs. Biosci Rep. 2021;41:BSR20211560.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Sommacale D, Rhaiem R, Piardi T, et al. Comments on “Liver resection using total vascular exclusion of the liver preserving the caval flow, in situ hypothermic portal perfusion and temporary porta-caval shunt: a new technique for central tumors.” Hepatobiliary Surg Nutr. 2017;6:207–9.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Yamanaka N, Furukawa K, Tanaka T, et al. Topical cooling-assisted hepatic segmentectomy for cirrhotic liver with hepatocellular carcinoma. J Am Coll Surg. 1997;184:290–6.

    CAS  PubMed  Google Scholar 

  22. Bismuth H. Surgical anatomy and anatomical surgery of the liver. World J Surg. 1982;6:3–9.

    Article  CAS  PubMed  Google Scholar 

  23. Proposal of a New comprehensive notation for hepatectomy: the "new world" terminology. Ann Surg. 2021; 274:1-3.

  24. Rahbari NN, Garden OJ, Padbury R, et al. Posthepatectomy liver failure: a definition and grading by the international study group of liver surgery (ISGLS). Surgery. 2011;149:713–24.

    Article  PubMed  Google Scholar 

  25. Koch M, Garden OJ, Padbury R, et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the international study group of liver surgery. Surgery. 2011;149:680–8.

    Article  PubMed  Google Scholar 

  26. Thomas ME, Blaine C, Dawnay A, et al. The definition of acute kidney injury and its use in practice. Kidney Int. 2014;87:62–73.

    Article  PubMed  Google Scholar 

  27. Rahbari NN, Garden OJ, Padbury R, et al. Post-hepatectomy haemorrhage: a definition and grading by the international study group of liver surgery (ISGLS). HPB (Oxford). 2011;13:528–35.

    Article  PubMed  Google Scholar 

  28. Maslove DM, Chen BT, Wang H, et al. The diagnosis and management of pleural effusions in the ICU. J Intensive Care Med. 2011;28:24–36.

    Article  PubMed  Google Scholar 

  29. Slankamenac K, Graf R, Barkun J, et al. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013;258:1–7.

    Article  PubMed  Google Scholar 

  30. Azoulay D, Lucidi V, Andreani P, et al. Ischemic preconditioning for major liver resection under vascular exclusion of the liver preserving the caval flow: a randomized prospective study. J Am Coll Surg. 2006;202:203–11.

    Article  PubMed  Google Scholar 

  31. Fu SY, Lai EC, Li AJ, et al. Liver resection with selective hepatic vascular exclusion: a cohort study. Ann Surg. 2009;249:624–7.

    Article  PubMed  Google Scholar 

  32. Si-Yuan F, Yee LW, Yuan Y, et al. Pringle manoeuvre versus selective hepatic vascular exclusion in partial hepatectomy for tumours adjacent to the hepatocaval junction: a randomized comparative study. Int J Surg. 2014;12:768–73.

    Article  PubMed  Google Scholar 

  33. Allard MA, Dondero F, Sommacale D, et al. Liver packing during elective surgery: an option that can be considered. World J Surg. 2011;35:2493–8.

    Article  PubMed  Google Scholar 

  34. Faitot F, Addeo P, Besch C, et al. Passive mesenterico-saphenous shunt: An alternative to portocaval anastomosis for tailored portal decompression during liver transplantation. Surgery. 2019;165:970–7.

    Article  PubMed  Google Scholar 

  35. Azoulay D, Salloum C, Eshkenazi R, et al. Access to the portal system via the mesentery for establishing venous bypass in liver transplantation. Liver Transpl. 2019;25:807–10.

    Article  PubMed  Google Scholar 

  36. Rössler F, Sapisochin G, Song G, et al. Defining benchmarks for major liver surgery: a multicenter analysis of 5202 living liver donors. Ann Surg. 2016;264:492–500.

    Article  PubMed  Google Scholar 

  37. Smyrniotis VE, Kostopanagiotou GG, Contis JC, et al. Selective hepatic vascular exclusion versus Pringle maneuver in major liver resections: prospective study. World J Surg. 2003;27:765–9.

    Article  PubMed  Google Scholar 

  38. Zhou W, Li A, Pan Z, et al. Selective hepatic vascular exclusion and Pringle maneuver: a comparative study in liver resection. Eur J Surg Oncol. 2008;34:49–54.

    Article  CAS  PubMed  Google Scholar 

  39. Zhang J, Lai EC, Zhou WP, et al. Selective hepatic vascular exclusion versus Pringle manoeuvre in liver resection for tumours encroaching on major hepatic veins. Br J Surg. 2012;99:973–7.

    Article  CAS  PubMed  Google Scholar 

  40. Olthof PB, Reiniers MJ, Dirkes MC, et al. Protective mechanisms of hypothermia in liver surgery and transplantation. Mol Med. 2016;21:833–46.

    Article  PubMed  Google Scholar 

  41. Mobarak S, Stott MC, Tarazi M, et al. Selective hepatic vascular exclusion versus pringle maneuver in major hepatectomy: a systematic review and meta-analysis. Front Surg. 2022;9:860721.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Azoulay D, Bhangui P, Pascal G, et al. The impact of expanded indications on short-term outcomes for resection of malignant tumours of the liver over a 30 year period. HPB (Oxford). 2017;19:638–48.

    Article  PubMed  Google Scholar 

  43. Barbier L, Ronot M, Monsinjon M, et al. Development of collateral pathways in tumor obstruction of confluence of the hepatic veins: neither fortuitous nor innocuous. J Am Coll Surg. 2016;223:595–601.

    Article  PubMed  Google Scholar 

  44. Morel A, Rivoire M, Basso V, et al. Identification of intra-hepatic communicating veins through the arch sign on CT-scan. Surg Radiol Anat. 2017;39:673–7.

    Article  PubMed  Google Scholar 

  45. Reiniers MJ, van Golen RF, Heger M, et al. In situ hypothermic perfusion with retrograde outflow during right hemihepatectomy: first experiences with a new technique. J Am Coll Surg. 2014;218:e7-16.

    Article  PubMed  Google Scholar 

  46. Reiniers MJ, Olthof PB, van Golen RF, et al. Hypothermic perfusion with retrograde outflow during right hepatectomy is safe and feasible. Surgery. 2017;162:48–58.

    Article  PubMed  Google Scholar 

  47. Azoulay D, Lim C, Salloum C, et al. Complex liver resection using standard total vascular exclusion, venovenous bypass, and in situ hypothermic portal perfusion: an audit of 77 consecutive cases. Ann Surg. 2015;262:93–104.

    Article  PubMed  Google Scholar 

  48. Serrablo A, Giménez-Maurel T, Utrilla Fornals A, et al. Current indications of ex-situ liver resection: a systematic review. Surgery. 2022;172:933–42.

    Article  PubMed  Google Scholar 

  49. Szilágyi ÁL, Mátrai P, Hegyi P, et al. Compared efficacy of preservation solutions on the outcome of liver transplantation: meta-analysis. World J Gastroenterol. 2018;24:1812–24.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Dinant S, van Veen SQ, Roseboom HJ, et al. Liver protection by hypothermic perfusion at different temperatures during total vascular exclusion. Liver Int. 2006;26:486–93.

    Article  PubMed  Google Scholar 

  51. Minor T, Efferz P, Fox M, et al. Controlled oxygenated rewarming of cold stored liver grafts by thermally graduated machine perfusion prior to reperfusion. Am J Transplant. 2013;13:1450–60.

    Article  CAS  PubMed  Google Scholar 

  52. Hoyer DP, Mathée Z, Gallinat A, et al. Controlled oxygenated rewarming of cold stored livers prior transplantation: first clinical application of a new concept. Transplantation. 2016;100:147–52.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Author notes

  1. Alejandro Serrablo MD

    Present address: Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain

  2. Chetana Lim MD, PhD

    Present address: Department of Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Villejuif, France

Authors and Affiliations

  1. Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France

    Daniel Azoulay MD, PhD, Chady Salloum MD, Marc-Antoine Allard MD, PhD, Pierluigi Romano MD, Daniel Pietraz MD, PhD & Nicolas Golse MD, PhD

  2. Centre Hépato-Biliaire, Department of Anesthesiology, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France

    Maya Moussa MD

Authors
  1. Daniel Azoulay MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chady Salloum MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marc-Antoine Allard MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Alejandro Serrablo MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Maya Moussa MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Pierluigi Romano MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Daniel Pietraz MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Nicolas Golse MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Chetana Lim MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Daniel Azoulay MD, PhD.

Ethics declarations

Disclosure

The authors have declared that no competing interests exist and there were no sources of funding.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file 1 (MP4 234302 kb)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Azoulay, D., Salloum, C., Allard, MA. et al. Complex Hepatectomy Under Total Vascular Exclusion of the Liver Preserving the Caval Flow with Portal Hypothermic Perfusion and Temporary Portacaval Shunt: A Proof of Concept. Ann Surg Oncol (2024). https://doi.org/10.1245/s10434-024-15227-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1245/s10434-024-15227-7

Search

Navigation