Complex liver resection with in situ hypothermic portal perfusion

Abstract

Introduction: Total vascular exclusion (TVE) of the liver might be required for complex liver resection. Standard TVE is contraindicated in some situations harboring a high risk of prolonged normothermic ischemia related morbidity. In situ hypothermic portal perfusion (HPP) can be used to overcome prolonged TVE consequences. Methods: This study is a prospective observational case series from January 2012 to December 2016, including patients with malignant tumors involving the vena cava and/or the hepatocaval confluence. Two surgical techniques were used: standard TVE with HPP and venovenous bypass and HPP with preservation of the caval flow using a temporary porto-caval shunt. Results: During the study period, 443 liver resections were performed in our department. Among them, fourteen (3.1%) were performed using HPP. Mean age was 55 years. Twelve (86%) patients had underlying liver disease. Mean tumor size was 87 mm (40-170mm). Mean operative time was 470 mn (360-580mn). Vascular reconstruction was performed in 4 (28.6%) patients. The 90-day mortality rate was 7.1% (1 patient). Four (28.6%) patients experienced grade III of Clavien-Dindo classification postoperative morbidity. No cases of postoperative liver failure or renal insufficiency were observed. Conclusion: HPP should be considered in patients requiring complex liver resections for centrally located tumors involving the hepatocaval confluence as it allows preservation of the future liver remnant function. Meanwhile, such resections should be indicated in selected patients with low comorbidity and good performance status because of a high morbidity rate.