Total Vascular Exclusion for Hepatic Resection in Cirrhotic Patients

Abstract

Hepatic vascular exclusion with double venovenous bypass using a centrifugal force pump was used in major hepatic resections in eight patients with hepatocellular carcinoma combined with cirrhosis, and results were compared with those in four patients with hepatocellular carcinoma without cirrhosis and eight with metastatic tumors without cirrhosis among 521 patients undergoing liver resection. Concomitant resection of the retrohepatic inferior vena cava was performed in three of eight patients with cirrhosis and five of 12 patients without cirrhosis. All patients, except one with cirrhosis, tolerated major resection without any hemodynamic impairment, which is often observed in hepatic vascular exclusion without venovenous bypass. One patient, whose complete inflow occlusion period was 70 minutes, died of liver failure. In this patient, the recovery of the arterial ketone body ratio above 1.0 was delayed until 3 days after recirculation, whereas the ratio in the others recovered promptly. Postoperative complications such as increased bilirubin level, pleural effusion, and gastrointestinal tract bleeding were observed in seven of eight patients with cirrhosis compared with six of 12 without cirrhosis. Hepatic vascular exclusion is feasible even in cirrhotics as long as it is applied with venovenous bypass and is kept within the time limit of 60 minutes.

No-Mortality Liver Resection for Hepatocellular Carcinoma in Cirrhotic and Noncirrhotic Patients

“…Our results and the oncological rationale indicate the surgical option is the best means of prolonging patients' survival. The good results obtained with an aggressive surgical approach for patients with advanced HCCs, even those with tumor thrombi in the portal trunk, 75 the therapeutic efficacy demonstrated by liver resection with respect to postoperative tumor recurrence, 16,76 and, moreover, in patients with such recurrence, the feasibility and safety of aggressive resection with vascular reconstruction 77 are signs that with the advent of dedicated technologies and modalities such as intraoperative US and portal venous branch embolization, surgical treatment should be used more rather than only for restricted indications.…”

Hepatic Vascular Exclusion With Preservation of the Caval Flow for Liver Resections

“…In addition, some patients with borderline cardiac function do not tolerate HVE because of persistent hypotension, despite adequate management. 3 This situation may require the use of venous bypass 23 or aortic clamping, 9 or may even make the resection impossible. Preservation of the caval flow with HVEPC avoids these consequences.…”

Difference in Hepatic Tissue Oxygenation between Total Vascular Exclusion and Inflow Occlusion of the Liver and the Possible Role of Hepatic Venous Blood under Liver Ischemia

“…Although TVE can be more advantageous with respect to the reduction of blood loss, TVE procedure needs to be performed in a radical resection safely for huge centrally located hepatic lesions or those in close proximity to the hepaticocaval confluence [6]. Considering the greater damage to the liver function as shown in the present study, a hepatic vascular exclusion with hypothermic liver perfusion [17] could be one of the modalities in order to decrease the damage of hepatic ischemia in such cases.…”

“…To reduce the amount of blood loss during a hepatectomy, there are two alternatives which have been used; one is hepatic inflow occlusion [1, 2] (including Pringle’s maneuver, abbreviated as IO) and the other is total vascular exclusion [3, 4, 5, 6] (TVE). TVE essentially includes the occlusion of the hepatic vein in addition to the inflow occlusion, however, the difference between the two procedures with respect to liver damage has not yet been clarified.…”