Ex Vivo Liver Resection and Autotransplantation for End-Stage Alveolar Echinococcosis: A Case Series

Abstract

contributed to this work equally.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.

Novel techniques and preliminary results of ex vivo liver resection and autotransplantation for end-stage hepatic alveolar echinococcosis: A study of 31 cases

“…Another patient died of acute cerebral hemorrhage; we speculate that this event was caused by excessive postoperative anticoagulant therapy. The most frequent cause of postoperative morbidity was bile leakage, with an incidence of 12.9% (4/31), which is lower than the incidence of 46.7% reported by Wen et al 22. Stenosis was detected at the HV in 1 case after 2 months of follow‐up, which may be a result of anastomosis scarring or hepatic vein kinking caused by pressure from the enlarged liver graft.…”

“…Thus ERAT was introduced. Since Wen et al 36 reported a case with such a technique in 2011, a few centers have also started using this approach 18, 22, 36, 37. Two deaths were reported previously, 1 from PV thrombosis 37 and 1 from acute liver failure in POD12 22.…”

“…The standard liver volume (SLV) was calculated following the experience of Urata et al20, 21 For patients with highly suspected extrahepatic metastases, positron emission tomography‐computed tomography (PET‐CT) was essential to determine whether there were any potential surgical contraindications. Ultrasonography (US) evaluation of the large abdomen vessels was necessary to assess the vascular flow status and the presence or absence of “rich collateral circulation.”22 US of the bilateral great saphenous vein (GSV) was performed to evaluate its diameter and length for the reconstruction of the RHVC. If patients had persistent obstructive jaundice and biliary dilatation before the operation, X‐ray‐ or US‐guided percutaneous transhepatic cholangial drainage (PTCD) was performed to alleviate the bilirubin level and biliary obstruction.…”

Management of Advanced Hepatic Alveolar Echinococcosis: Report of 42 Cases

“…The result suggests OLT may benefit the advanced HAE patients with parasitic BuddChiari syndrome or when resection techniques have been exhausted and those with end-stage functional disorders caused by secondary biliary cirrhosis, secondary sclerosing cholangitis, and postnecrotic cirrhosis. [33][34][35][36][37] In summary, our study suggests aggressive treatment with a multimodality strategy could result in prolonged survival in patients with advanced HAE. Palliative resection may be beneficial for those with advanced HAE.…”

Right Liver Resection Techniques for Advanced Alveolar Echinococcosis with Vascular Invasion

“…The necessity of a complicated reconstruction of the afferent perfusion of Sg2 and Sg3 separately was the reason for preservation and resection ex vivo. Such indication is regarded as one of the possible and is presented in the largest presently published series of autotransplantations for alveolar echinococcosis, including 15 patients with 6.7% hospital lethality, absence of recurrences in 86.7% of patients and median follow-up for 21.6 months [26].…”