X. Yang1, W. Wang1, W. Wang1 1West China Hospital of Sichuan University,Department Of Liver Surgery & Liver Transplantation Center,Chengdu, SICHUAN, China
Introduction: In cases of invasion of the retrohepatic inferior vena cava (RIVC), especially those with a rich retroperitoneal collateral circulation, it is very challenging to decide whether replacement of the RIVC requires reconstruction or the use of an alternative graft. However, the application of RIVC resection without reconstruction in ex vivo liver resection and autotransplantation(ERAT) has not been fully characterized. We aimed to introduce the surgical technique for and describe the complications and long-term outcomes of RIVC resection without reconstruction in ERAT for advanced hepatic alveolar echinococcosis (HAE).
Methods: After removal of the entire liver, depending on the presence of a rich collateral circulation and stable blood volume, we chose not to rebuild the RIVC. Then, we chose an appropriate revascularization technique for the hepatic and renal veins. Finally, all ERAT procedures were completed, and short- and long-term outcomes were observed.
Results: Between February 2014 and August 2018, 5 of 77 advanced HAE patients who underwent ERAT required the described technique. One patient died of circulatory failure 1 day after surgery. Another four patients, with a median follow-up duration of 18 months (range, 10-25 months), demonstrated normal liver and kidney function, no thrombosis and no HAE recurrence.
Conclusions: Through the long-term results of ERAT, the pros and cons of not reconstructing the RIVC need to be re-examined. In cases with a rich collateral circulation, the RIVC can be reconstructed. However, in cases requiring the resection of multiple organs, RIVC reconstruction is not recommended. We recommend this procedure for use in ERAT (liver autotransplantation), Budd-Chiari syndrome, and primary IVC tumors but recommend that the surgeon think twice before not rebuilding the RIVC.
FIGURE 1.The main techniques for retrohepatic inferior vena cava (RIVC) resection without reconstruction in ex vivo liver resection and autotransplantation (ERAT). A. preoperative simulation of the extent of hepatic alveolar echinococcosis, including the right lower lung lobe and right kidney. B. preoperative inferior vena cava angiography shows the rich collateral circulation and right renal vein, retrohepatic inferior vena cava occlusion. C. diagram of reconstruction of patient 4 after liver autotransplantation. D. histological section of the all layers of RIVC showing a granulomatous inflammation with a necrotic center induced by Echinococcus multilocularis. Hematoxylin–eosin staining, x0.37. E. remnants of laminated layer of E. multilocularis. Hematoxylin–eosin staining, x400.
