Invited commentary

Abstract

As the authors point out, there have been only a few dozen cases of hepatectomies with inferior vena cava (IVC) reconstruction described in the literature, and this case report may be the first to describe a graft-enteric fistula. In the surgical oncology world, we have witnessed progressive aggressiveness in liver tumor resection. The ability to perform successfully these hepatectomies with concomitant IVC resection/reconstruction has depended in part on the evolution of better intraoperative equipment – energy devices and staplers for more efficient dissection and transaction of the liver parenchyma. In select hepatobiliary centers, these cases of hepatectomies with IVC resection/reconstruction may be considered on some routine basis. It remains unclear which patients may likely benefit from this radical surgery. I agree with the authors that the most relevant factors for the likely cause of this fistula would be the radiation therapy and the absence of an omental wrap. The routine use of an omental wrap between the IVC graft and the enteric limb is centrally important to significantly reduce the risk of fistula formation. Hepatobiliary surgeons are quite aware of the common recurrences of cholangitis after any biliary reconstruction. The presence of a synthetic graft should compel much more liberal consideration for antibiotics and earlier diagnostic studies to look for graft infection and fistula. Although I am eager to see comparison studies that may demonstrate comparable or better long-term patency rates and lower fistula rates with cryopreserved aortic allografts vs polytetrafluoroethylene/Dacron grafts, and especially for patients who may require radiation treatment in that field, I do realize that such comparison is difficult to perform due to the rarity of this condition. As the technology advances, along with our abilities to diagnose and manage such relatively rare but very complex complications, it would be our shared onus – between vascular surgeons and hepatobiliary surgeons – to be that much more selective of the patients to consider such radical resections. The difficulty of such diagnosis and surgical treatment of these fistulas is especially challenging in the present era of more itinerant surgeon cross-coverage, superspecialization, and more geographically mobile patients. Such circumstances require heightened awareness as provided by these journal reports and additional longitudinal studies. Looking forward, I anticipate that many future patients who develop such fistulas may not be so fortunate to have a similar indolent course as this reported patient (2-year history of recurrent sepsis, 11 years of survival from the original tumor resection), with such chronicity as to allow sufficient collateralization to avoid reconstruction at the time of fistula repair. The typical patient in the community who develops such a fistula may be more likely to succumb to acute sepsis or graft blow out. I believe that there would be a significant self-selection, that these fistulas would take a long time to develop, and, therefore, only a small number of liver cancer survivors (with original tumors so locally aggressive as to require IVC resection) would present with fistula formation. Inferior vena cava graft-enteric fistula after extended hepatectomy with caval replacementJournal of Vascular SurgeryVol. 55Issue 1PreviewA case of an inferior vena cava (IVC) graft-enteric fistula manifesting with recurrent sepsis 11 years after a right hepatectomy extending to segments I and IV, the extrahepatic bile duct, and IVC followed by chemotherapy and external-beam radiation therapy is described. A preoperative workup revealed graft thrombosis with air bubbles inside the lumen. Laparotomy found a chronic fistula between the graft and the enteric biliary loop. Removal of the graft without further vascular reconstruction, a take-down of the biliary loop, and a redo hepaticojejunostomy were performed successfully. Full-Text PDF Open Archive