Hypothermic ante situm Resection in Tumors of the Hepatocaval Confluence

Abstract

Primary liver malignancies together with metastatic liver tumors are among the most common tumors in human. The best available treatment option for these diseases is surgical resection. One major parameter which had been considered as contraindication for liver resection owing to technical difficulties in achieving tumor-free margins was the involvement of the hepatocaval confluence. To overcome this problem, several techniques including hypothermic in situ, ante situm and ex situ liver resection have been introduced. The common basis for these liver resections is the total vascular exclusion of the liver, and perfusion of the organ by preservation solution under hypothermic conditions. The major indications for the ante situm liver resection are tumors in the liver that are either unresectable or inadequately resectable by conventional surgery because they involve the venous confluence and/or the retrohepatic vena cava, or are in close proximity to them. This technique is a realistic option to achieve surgical cure or substantial gain of life time with quality of life in otherwise unresectable tumors of the liver. Due to fewer anastomoses, the ante situm approach is easier and safer than the ex situ approach, with an acceptable morbidity and mortality rate. Patient selection is of utmost importance to achieve a good outcome. To minimize the postoperative morbidities and mortality, this procedure requires a multidisciplinary approach and should be performed in experienced centers with a high case volume of hepatobiliary surgeries.

Ex situ Liver Resection for Unresectable Tumors

“…This technique, which has resulted in a significant reduction of morbidity and mortality rates [37], involves the full mobilization of the vena cava from its dorsal attachments, but not from the liver. The biliary and hepatic arteries are not divided, but the procedure is similar in other ways to ex situ resection.…”

Current status of the organ replacement approach for malignancies and an overture for organ bioengineering and regenerative medicine

“…129 Since then, liver tumors involving the confluence of hepatic veins and/or the retrohepatic vena cava were resected by this approach in more than 50 patients and every report underscores the paramount importance of deliberate patient selection. 130,134,[138][139][140][141][142] Ciancio et al depicted the use of the mobilization technique in LT for resection of renal cell carcinoma with tumor thrombus in the inferior vena cava 143 and en bloc mobilization of the pancreas and spleen, which was derived from multivisceral transplantation as well as organ procurement, for resection of large tumors in the left upper abdomen. 144 Both procedures were successfully performed with minimum risk while maximizing the chance of complete resection.…”

Gefäßersatz in der abdominellen Tumorchirurgie

“…Allen Verfahren gemein ist die unbedingte Notwendigkeit, zur Ermög-lichung eines Langzeitüberlebens durch gegebenenfalls multimodale, mehrstufige Konzepte eine R0 Situation zu erreichen. Das Problem einer konventionellen Resektion unzugänglicher Tumoren tritt im klinischen Alltag eines hochspezialisierten Zentrums der hepatobiliären Chirurgie jedoch weiterhin auf [27,28]. Die Erfahrung mit der hypothermen Organkonservierung bei der Lebertransplantation motivierte Joseph G. Fortner 1970 dazu, die Techniken der Lebertransplantation für die Resektion von Lebertumoren zu adaptieren.…”

“…Die Erfahrung mit der hypothermen Organkonservierung bei der Lebertransplantation motivierte Joseph G. Fortner 1970 dazu, die Techniken der Lebertransplantation für die Resektion von Lebertumoren zu adaptieren. Fortner berichtete 1974 [9] über 29 Leberresektionen unter hypothermer Perfusion des vom Blutstrom ausgeklemmten Organes mit 4°C kalter Ringer-Lösung (für eine Über-sicht s. [28]). Bei großen, zentral gelegenen Tumoren mit Invasion des venösen Ausflusstraktes und/oder der retrohepatischen V. cava inferior (.…”