Aggressive combined resection of hepatic inferior vena cava, with replacement by a ringed expanded polytetrafluoroethylene graft, in living‐donor liver transplantation for hepatocellular carcinoma beyond the Milan criteria

Abstract

We present the cases of two patients with hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) who underwent living-donor liver transplantation (LDLT) combined with aggressive hepatic venacaval resection and replacement of the hepatic inferior vena cava (IVC) by an artificial vascular graft. The aim of the resection and replacement of the hepatic IVC was to resect completely a latent cancer adjacent to the hepatic IVC and to avoid micrometastasis via the hepatic veins during increased manipulation of the native liver with HCC. First, the hepatic hilus was dissected and the infrahepatic IVC was encircled. After minimum mobilization of the liver, the common orifice of the middle and left hepatic veins and suprahepatic IVC was encircled. Venovenous bypass (VVB) was started to stabilize systemic hemodynamics. After cross-clamping of the infrahepatic and suprahepatic IVC, the IVC was divided at the site just below the confluence of the common orifice of the middle and left hepatic veins and its infrahepatic site. Then, all retroperitoneal attachments of the right lobe were dissected and the native liver was resected with the retrohepatic IVC. The IVC was replaced by a ringed expanded polytetrafluoroethylene (e-PTFE) graft. Infrahepatic venous recirculation ended the VVB. An extended left-lobe graft was implanted. The e-PTFE grafts were covered with the greater omentum to avoid infection. The operations were completed safely. The postoperative courses were free of complications related to the reconstruction of the hepatic IVC. One patient developed recurrence in the left adrenal gland. LDLT combined with hepatic venacaval resection and replacement by an e-PTFE graft for HCC beyond the MC could be safe and feasible under VVB. Further studies are needed to confirm to what extent this procedure could prevent post-transplant recurrence in HCC beyond the MC.