Successful curative extracorporeal hepatic resection for far-advanced hepatocellular carcinoma in an adolescent patient

Abstract

Hepatectomy is the principal treatment for hepatocellular carcinoma (HCC); however, some HCCs are not resectable by conventional hepatic resection. In such apparently incurable cases, extracorporeal hepatic resection (ECHR) may offer an option for survival. We recently encountered a juvenile patient with faradvanced HCC who was successfully treated by ECHR with favorable long-term survival. A 17-year-old woman was referred to our hospital with a huge liver mass and was admitted for evaluation. She had no history of serious illness, surgery, or hospitalization and no notable family history. Of the serum tumor markers examined, a-fetoprotein (335.5 ng/mL, normal < 20 ng/mL) and des-c-carboxy prothrombin (1988 mAU/mL, normal < 40 mAU/mL) were elevated. She was serologically negative for anti– hepatitis C virus antibody and hepatitis B surface antigen, but she was positive for hepatitis B core antigen. Computed tomography with contrast enhancement showed an 18 cm 12 cm tumor in the center of the liver (Fig. 1a). One intrahepatic metastatic tumor was found in the left lateral segment of the liver. The first left branch of the portal vein was completely involved in the liver. The inferior vena cava (IVC) and the right hepatic vein (RHV) were completely surrounded by the tumor and were remarkably dislocated to the anterior side of the body (Fig. 1b,c). Celiac arterial angiography and indirect portography revealed an intact hepatic artery and the portal vein of the right posterior branch (Fig. 1d,e). The estimated remnant liver volume after left trisegmentectomy was 508 mL, which corresponded to 52.6% of the patient’s standard liver volume (Fig. 1f). On the basis of these findings, standard in situ hepatic resection was considered unfeasible, and ECHR was planned instead. Laparotomy revealed that the liver was severely enlarged because of the huge tumor, but the nontumorous liver parenchyma seemed to be normal. After the division of the proper hepatic artery and the common bile duct, the total liver was detached from the diaphragm. Intraoperative ultrasound was used to determine the cutting line at the back table. Vascular clamps were then applied, and this was followed by division of the portal vein and the suprahepatic and infrahepatic IVC, after which total hepatectomy was performed (Fig. 2a). A pump-driven portosystemic venovenous bypass was established from the portal vein and the left saphenous vein to the left axillary vein. The explanted liver was flushed with University of Wisconsin solution. The hepatic parenchymal dissection was performed with a Cavitron ultrasonic surgical aspirator (Valleylab, Inc., Boulder, CO), and the vessels were divided with ligations or clips. The IVC was completely dissected from the tumor and the dorsal liver. Extended left lobectomy with the caudate lobe was performed at the back table. After hepatic resection, vascular and biliary leakage tests were performed by the injection of University of Wisconsin solution, and the leakage points were repaired with fine sutures. The actual weight of the explanted liver was 2050 g (Fig. 2d), and the weight of the liver autograft