Abstract
Background/purpose
We present the cases of two patients with hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) who underwent living-donor liver transplantation (LDLT) combined with aggressive hepatic venacaval resection and replacement of the hepatic inferior vena cava (IVC) by an artificial vascular graft. The aim of the resection and replacement of the hepatic IVC was to resect completely a latent cancer adjacent to the hepatic IVC and to avoid micrometastasis via the hepatic veins during increased manipulation of the native liver with HCC.
Methods
First, the hepatic hilus was dissected and the infrahepatic IVC was encircled. After minimum mobilization of the liver, the common orifice of the middle and left hepatic veins and suprahepatic IVC was encircled. Venovenous bypass (VVB) was started to stabilize systemic hemodynamics. After cross-clamping of the infrahepatic and suprahepatic IVC, the IVC was divided at the site just below the confluence of the common orifice of the middle and left hepatic veins and its infrahepatic site. Then, all retroperitoneal attachments of the right lobe were dissected and the native liver was resected with the retrohepatic IVC. The IVC was replaced by a ringed expanded polytetrafluoroethylene (e-PTFE) graft. Infrahepatic venous recirculation ended the VVB. An extended left-lobe graft was implanted. The e-PTFE grafts were covered with the greater omentum to avoid infection.
Results
The operations were completed safely. The postoperative courses were free of complications related to the reconstruction of the hepatic IVC. One patient developed recurrence in the left adrenal gland.
Conclusion
LDLT combined with hepatic venacaval resection and replacement by an e-PTFE graft for HCC beyond the MC could be safe and feasible under VVB. Further studies are needed to confirm to what extent this procedure could prevent post-transplant recurrence in HCC beyond the MC.
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References
Yao FY. Liver transplantation for hepatocellular carcinoma: beyond the Milan criteria. Am J Transplant. 2008;8:1982–9.
Taketomi A, Soejima Y, Yoshizumi T, Uchiyama H, Yamashita Y, Maehara Y. Liver transplantation for hepatocellular carcinoma. J Hepatobiliary Pancreat Surg. 2008;15:124–30.
Ito T, Takada Y, Ueda M, Haga H, Maetani Y, Oike F, et al. Expansion of selection criteria for patients with hepatocellular carcinoma in living donor liver transplantation. Liver Transpl. 2007;13:1637–44.
Takada Y, Ito T, Ueda M, Sakamoto S, Haga H, Maetani Y, et al. Living donor liver transplantation for patients with HCC exceeding the Milan criteria: a proposal of expanded criteria. Dig Dis. 2007;25:299–302.
Azoulay D, Andreani P, Maggi U, Salloum C, Perdigao F, Sebagh M, et al. Combined liver resection and reconstruction of the supra-renal vena cava: the Paul Brousse experience. Ann Surg. 2006;244:80–8.
Delis SG, Madariaga J, Ciancio G. Combined liver and inferior vena cava resection for hepatic malignancy. J Surg Oncol. 2007;96:258–64.
Facciuto ME, Singh MK, Rocca JP, Rochon C, Rodriguez Davalos MI, Eshghi M, et al. Benefits of liver transplantation surgical techniques in the management of extensive retroperitoneal tumors. World J Surg. 2008;32:2403–7.
Hoffmann K, Weigand MA, Hillebrand N, Buchler MW, Schmidt J, Schemmer P. Is veno-venous bypass still needed during liver transplantation? A review of the literature. Clin Transplant. 2009;23:1–8.
Khan S, Silva MA, Tan YM, John A, Gunson B, Buckels JA, et al. Conventional versus piggyback technique of caval implantation; without extra-corporeal veno-venous bypass A comparative study. Transpl Int. 2006;19:795–801.
Tzakis A, Todo S, Starzl TE. Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg. 1989;210:649–52.
Liu CL, Fan ST, Cheung ST, Lo CM, Ng IO, Wong J. Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma: a prospective randomized controlled study. Ann Surg. 2006;244:194–203.
Mehrabi A, Mood ZA, Fonouni H, Kashfi A, Hillebrand N, Muller SA, et al. A single-center experience of 500 liver transplants using the modified piggyback technique by Belghiti. Liver Transpl. 2009;15:466–74.
Mangus RS, Fridell JA, Vianna RM, Cooper AB, Jones DT, Tector AJ. Use of the piggyback hepatectomy technique in liver transplant recipients with hepatocellular carcinoma. Transplantation. 2008;85:1496–9.
Bhattacharjya S, Bhattacharjya T, Quaglia A, Dhillon AP, Burroughs AK, Patch DW, et al. Liver transplantation in cirrhotic patients with small hepatocellular carcinoma: an analysis of pre-operative imaging, explant histology and prognostic histologic indicators. Dig Surg. 2004;21:152–9. (discussion 159–60).
Parfitt JR, Marotta P, Alghamdi M, Wall W, Khakhar A, Suskin NG, et al. Recurrent hepatocellular carcinoma after transplantation: use of a pathological score on explanted livers to predict recurrence. Liver Transpl. 2007;13:543–51.
Soejima Y, Taketomi A, Yoshizumi T, Uchiyama H, Aishima S, Terashi T, et al. Extended indication for living donor liver transplantation in patients with hepatocellular carcinoma. Transplantation. 2007;83:893–9.
Taketomi A, Sanefuji K, Soejima Y, Yoshizumi T, Uhciyama H, Ikegami T, et al. Impact of des-gamma-carboxy prothrombin and tumor size on the recurrence of hepatocellular carcinoma after living donor liver transplantation. Transplantation. 2009;87:531–7.
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Matsuda, H., Sadamori, H., Shinoura, S. et al. Aggressive combined resection of hepatic inferior vena cava, with replacement by a ringed expanded polytetrafluoroethylene graft, in living-donor liver transplantation for hepatocellular carcinoma beyond the Milan criteria. J Hepatobiliary Pancreat Sci 17, 719–724 (2010). https://doi.org/10.1007/s00534-010-0287-z
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DOI: https://doi.org/10.1007/s00534-010-0287-z