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COMBINED EXTENDED RIGHT HEPATECTOMY WITH INFERIOR VENA CAVA RESECTION AND RECONSTRUCTION WITH GORE-TEX GRAFT

Authors:
Klaus Steinbruck at Hospital Federal de Bonsucesso
Klaus Steinbruck
Renato Cano
Renato Cano
Hanna Vasconcelos at Hospital Federal de Ipanema
Hanna Vasconcelos
Bruno RANGEL
Bruno RANGEL
Bruno RANGEL
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E-VIDEO
152 • Arq Gastroenterol • 2 02 2. v. 59 nº 1 jan/mar
Malignant liver tumors can directly invade the inferior vena
cava (IVC) due to anatomical proximity. In such cases, hepa-
tectomy combined to IVC resection may be required to achieve
negative surgical margins
(1,2)
. This approach becomes more com-
mon, due to progress in surgical techniques and perioperative
management
(3,4)
.
Herein, we present a case of a 42-year-old woman with a 23
cm hypervascular liver mass located on the right liver, extended
to segments one and four, encompassing completely the IVC
circumference, near the root of the left hepatic vein (LHV) (FI-
GURE1). Preoperative diagnosis was between liver cell adenoma
or hepatocellular carcinoma (HCC). Patient was taken to surgery,
which was performed through a bilateral subcostal incision with
Combined extended right hepatectomy with
inferior vena cava resection and reconstruction
with Gore-Tex graft
Klaus STEINBRÜCK, Renato CANO, Hanna VASCONCELOS, Bruno RANGEL,
Reinaldo FERNANDES and Marcelo ENNE
Received: 3 June 2021
Accepted: 3 August 2021
Declared conflict of interest of all authors: none
Disclosure of funding: no funding received
Hospital Federal de Ipanema, Unidade de Cirurgia Hepatobiliar, Rio de Janeiro, RJ, Brasil.
Corresponding author: Klaus Steinbrück. E-mail: steinbruck@gmail.com
E-VIDEO: https://youtu.be/pD4dUVKyiI8
AG-2021-120
doi.org/10.1590/S0004-2803.202200001-26
FIGURE 1. Axial (A) and coronal (B) CT scan images showing a hypervascular liver mass (*) involving the retrohepatic IVC (arrows).
midline extension (E-VIDEO). Initially, we performed a doppler
ultrasonography to analyze the relationship between the tumor
and vascular structures and assure that the LHV was not involved
by the lesion. Next, the liver pedicle and infrahepatic IVC were
taped to perform the liver’s total vascular exclusion (TVE). Then,
the right hepatic artery, right portal vein and right biliary duct
were dissected, ligated and divided. Portal and arterial branches
to caudate lobe were also divided. Suprahepatic IVC was then
isolated and encircled. Hepatotomy was performed through the
anterior approach, using an ultrasonic dissector/aspirator. Besides
the selective ischemia of the right liver, Pringle maneuver was
applied (two periods of 15-minutes clamping with 5-minutes of
clamping-free), in order to minimize blood loss and ischemic time.
Steinbrück K, Cano R, Vasconcelos H, Rangel B, Fernandes R, Enne M
Combined extended right hepatectomy with inferior vena cava resection and reconstruction with gore-tex graft
Arq Gastroenterol • 2022. v. 59 nº 1 jan/mar • 153
After identifying the middle hepatic vein in the transection plane,
TVE was performed by clamping successively the portal triad,
infrahepatic and suprahepatic IVC. Extended right hepatectomy
and IVC resection was then completed. The LHV in the native vena
cava remained untouched.
IVC was reconstructed with a 20 mm Gore-Tex graft, rstly
sutured to the suprahepatic IVC. Sequentially the suprahepatic
clamp was released and placed below the insertion of the LHV,
allowing unclamping of the hepatic pedicle, for restoration of
liver perfusion and diminishing ischemic time. The graft was then
sutured to the infrahepatic IVC and the last clamp was released.
TVE time was 20 minutes. Patient recovered well and was dis-
charged on the 6
th
post-operative day. Histopathological analysis
conrmed HCC. Patient is still alive 36 months after surgery, with
graft patency (FIGURE 2).
Combined extended right hepatectomy and IVC resection is a
safe and feasible procedure, that should be performed by a hepa-
tobiliary team experienced in complex hepatectomies and liver
transplantation. Despite being an aggressive surgical procedure, it
may be the only curative option for patients with massive tumors
involving the IVC.
Authors' contribution
Steinbrück K, Cano R, Vasconcelos H, Rangel B, Fernandes
R and Enne M: participated in the surgical procedure, designed
the case report, collected data, wrote the paper, critically reviewed
and approved the nal version to be published.
REFERENCES
1. Goto H, Hashimoto M, Akamatsu D, Shimizu T, Miyama N, Tsuchida K, et
al. Surgical resection and inferior vena cava reconstruction for treatment of the
malignant tumor: technical success and outcomes. Ann Vasc Dis. 2014;7:120-6.
2. Bower TC, Nagorney DM, Cherry-Junior KJ, Toomey BJ, Hallett JW, Panneton
JM, et al. Replacement of the inferior vena cava for malignancy: an update. J Vasc
Surg. 2000;31:270-81.
Orcid
Klaus Steinbrück: 0000-0002-3601-7272.
Renato Cano: 0000-0002-4370-8194.
Hanna Vasconcelos: 0000-0002-6753-9372.
Bruno Rangel: 0000-0001-6744-9396.
Reinaldo Fernandes: 0000-0001-8759-2552.
Marcelo Enne: 0000-0002-8714-3295.
FIGURE 2. Long term postoperative axial CT scan image showing the
hypertrophied left lateral liver sector (*) and patent IVC graft (arrow).
Steinbrück K, Cano R, Vasconcelos H, Rangel B, Fernandes R, Enne M. Hepatectomia direita alargada combinada com ressecção da veia cava inferior
e reconstrução com prótese de Gore-Tex. Arq Gastroenterol. 2022;59(1):152-3.
3. Tomimaru Y, Eguchi H, Wada H, Doki Y, Mori M, Nagano H. Surgical outcomes
of liver resection combined with inferior vena cava resection and reconstruction
with articial vascular graft. Dig Surg. 2019;36:502-8.
4. Papamichail M, Marmagkiolis K, Pizanias M, Koutserimpas C, Heaton N. Safety
and efcacy of inferior vena cava reconstruction during hepatic resection. Scand
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... (11,12) No obstante, existen casos donde el tumor se muestra con un perfil invasivo de las vísceras cercanas con las consiguientes repercusiones ligadas a la afectación de los órganos. (13,14) En el momento actual, y dadas las características de este tipo de tumores, parece ser que, de forma generalizada, con algunas excepciones, (15) se admite que la cirugía radical con extirpación del tumor y órganos afectados es la mejor opción terapéutica; aunque también se considera como aceptable la extirpación parcial como terapia paliativa. (15,16,17) Desde el punto de vista reconstructivo, la actuación se centra fundamentalmente en la vena cava. ...
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Safety and Efficacy of Inferior Vena Cava Reconstruction During Hepatic Resection
Article
Full-text available
  • Sep 2018
Background and aims: Patients with liver tumors involving the inferior vena cava have a poor outcome without surgery. Liver resection en bloc with inferior vena cava resection and reconstruction is now performed in many centers. The purpose of this study is to investigate the safety and efficacy of inferior vena cava reconstruction during hepatic resection. Materials and methods: A review of 12 centers reporting 240 patients with combined hepatectomy and inferior vena cava resection and reconstruction for malignant tumors was performed. Sample size, patient characteristics, histological type of the tumor, method of reconstruction, complications, and long-term survival (1-, 2-, and 5-year survival) were evaluated. Results: A total of 240 patients from 12 institutions (male 58%) with mean age 54 years underwent combined liver resection and inferior vena cava resection and reconstruction for colorectal liver metastases (43%), cholangiocarcinomas (26%), hepatocellular carcinomas (19%), leiomyosarcomas (4%), and other tumors (7.9%). Reconstruction included primary closure (35.8%), patch repair (13.3%), or interposition graft (50.8%) In-hospital mortality was 6.25% and overall morbidity was 42.1%. 1- and 10-year survival rates were 79.7% and 28.9%, respectively. Conclusion: Tumors arising in or extending to inferior vena cava that require liver resection should be considered for surgery as it can be performed with an acceptable mortality and morbidity in centers with liver transplantation and hepato-pancreato-biliary facilities.
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Surgical Resection and Inferior Vena Cava Reconstruction for Treatment of the Malignant Tumor: Technical Success and Outcomes
Article
Full-text available
  • Jul 2014
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Article
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Background/aim: Inferior vena cava (IVC) resection and reconstruction with concomitant liver resection sometimes represent the only chance for patients with liver tumors involving the IVC to get cured. However, surgical outcomes of liver resection with IVC resection and reconstruction using an artificial vascular graft have not been well investigated. Methods: Out of a total of 1,179 cases, only 12 involving liver resection between 1998 and 2016 at our institution included IVC resection and reconstruction using an artificial vascular graft. An expanded polytetrafluoroethylene graft was used for the IVC reconstruction in all 12 cases. We investigated the surgical outcomes of these combined surgeries. Results: The median operative time was 650 min and the median blood loss was 2,600 mL. Postoperative complications (≥ grade III in the Clavien-Dindo classification) developed in 2 patients - 1 case of bleeding and one of bile leakage. There were no cases of operative mortality. No complications associated with the vascular graft were observed throughout the postoperative follow-up period, and the grafts remained patent in all cases. Conclusions: These results indicate favorable surgical outcomes of liver resection combined with IVC resection and reconstruction.
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Replacement of the inferior vena cava for malignancy: An update
Article
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Resection and replacement of the inferior vena cava (IVC) to remove malignant disease is a formidable procedure. Since our initial report with IVC replacement for malignancy, we have maintained an aggressive approach to these patients. The purpose of this review is to update our experience with regard to patient selection, operative technique, and early and late outcome. All patients who had IVC replacement for primary (n = 2) or secondary (n = 27) vena cava tumors from April 1990 to May 1999 were reviewed. Tumor location and type, clinical presentation, the segment of IVC replaced, graft patency, performance status of the patient, and tumor recurrence and survival data were collected. Late follow-up data were available for all but one patient. The IVC was replaced in 28 patients with large diameter (> or =14 mm) externally supported ePTFE grafts and with a panel graft of superficial femoral vein in the other. Three patients had a femoral arteriovenous fistula. Graft patency was determined before hospital dismissal and in follow-up by vena cavography, computed tomography, ultrasonography, or magnetic resonance imaging. There were 18 women and 11 men, with a mean age of 53.1 years (range, 16-88 years). Over one half of patients had symptoms from their tumor. IVC replacement was at the suprarenal segment in 15 patients, of whom 13 had concomitant major hepatic resection, at the infrarenal segment in 10, at both caval segments in three, and at the renal vein confluence in one. There were two early deaths (6.9%). One patient died intraoperatively of coagulopathy during liver resection and suprarenal IVC replacement. The other death occurred 4 months postoperatively, from multisystem organ failure that resulted in graft infection and occlusion. Twelve patients had one or more major complications- cardiopulmonary problems in five; bleeding in five; chylous ascites or large pleural effusions in two patients each; and lower extremity edema with tibial vein thrombosis in one. The mean follow-up was 2.8 years (range, 2.7 months to 6.3 years). Two late graft occlusions occurred: one at 7.5 months, the other, from tumor recurrence, at 6.3 years. There have been no other late graft-related complications. All 11 late deaths were caused by the progression of malignant disease. Of 16 survivors, 12 have no evidence of disease and four have either regional or distant metastatic recurrence. Initial postoperative performance status was good or excellent for most survivors. Aggressive surgical management may offer the only chance for cure or palliation of symptoms for patients with primary or secondary IVC tumors. Our experience suggests that vena cava replacement may be performed safely with low graft-related morbidity and good patency in carefully selected patients.
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