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In Situ Hypothermic Perfusion of the Liver for Complex Hepatic Resection: Surgical Refinements

Abstract

Introduction

While total vascular exclusion (TVE) with veno-venous bypass and hypothermia may be undertaken to increase liver tolerance for complex liver resection, these procedures are still associated with elevated rates of postoperative complications and mortality. In particular, one of the main issues of this strategy is the management of bleeding after declamping, which is enhanced by both hypothermic state and acidosis. To overcome this high risk of morbidity, several technical refinements might be undertaken and here described (with video).

Methods

All patients, requiring TVE >60 min and liver cooling during hepatectomy, were retrospectively included in this study. Technical key points as (a) patient selection, (b) anesthetic management, (c) two-surgeon’s technique, (d) preparation for clamping, (e) veno-venous bypass, (f) cooling of the liver, and (g) parenchymal transection, rewarming, and declamping are described and detailed.

Results

From 2011 to 2013, we included 8 cases of liver resection with TVE, veno-venous bypass, and hypothermia for malignant disease. Due to the technical refinements, median observed overall blood loss of 550 ml (300–900) including 200 ml (50–300) at declamping and transfusion of packed red blood cell (PRBC) units was required in 5 patients with a mean of 1.25 PRBC/patient.

Conclusion

The association of TVE, veno-venous bypass, and liver cooling can reduce the time of transection, and blue dye injection and liver rewarming before declamping can reduce blood loss and coagulopathy. Altogether, limited blood loss can be achieved for these complex procedures and may allow to decreasing morbidity.

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Fig. 1

Abbreviations

I/R:

Ischemia reperfusion

ICU:

Intensive care unit

OS:

Overall survival

DFS:

Disease free survival

min:

Minutes

TVE:

Total vascular exclusion

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Author information

Correspondence to Raffaele Brustia.

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Conflict of interest

None of the authors have any conflict of interest.

Additional information

François Cauchy and Raffaele Brustia have contributed equally.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Preparing for clamping (IVC dissection and control and pedicular dissection). (Duration: 1′56″). Supplementary material 1 (M4 V 21963 kb)

Video 2: Veno-Venous By-pass,TVE of the Liver, cooling of the liver by hypothermic perfusion and topical cooling and parenchimal transection. (Duration: 4′31″). Supplementary material 2 (M4 V 123007 kb)

Blue dye injection and liver rewarming before declamping; IVC declamping, hemostasis and ablation of the cannulas. (Duration 1′15″). Supplementary material 3 (M4 V 25882 kb)

Video 1

Preparing for clamping (IVC dissection and control and pedicular dissection). (Duration: 1′56″). Supplementary material 1 (M4 V 21963 kb)

Video 2

Video 2: Veno-Venous By-pass,TVE of the Liver, cooling of the liver by hypothermic perfusion and topical cooling and parenchimal transection. (Duration: 4′31″). Supplementary material 2 (M4 V 123007 kb)

Video 3

Blue dye injection and liver rewarming before declamping; IVC declamping, hemostasis and ablation of the cannulas. (Duration 1′15″). Supplementary material 3 (M4 V 25882 kb)

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Cauchy, F., Brustia, R., Perdigao, F. et al. In Situ Hypothermic Perfusion of the Liver for Complex Hepatic Resection: Surgical Refinements. World J Surg 40, 1448–1453 (2016). https://doi.org/10.1007/s00268-016-3431-3

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Keywords

  • Liver Resection
  • Inferior Vena Cava
  • Portal Vein Embolization
  • Future Live Remnant
  • Adrenal Vein