Infrahepatic Inferior Vena Cava Research Articles

Perioperative outcomes of utilizing infrahepatic inferior vena cava clamping and Pringle maneuver duringhepatectomy: a meta-analysis.

Intraoperative bleeding during hepatectomy is primarily controlled through anaesthesiological interventions or surgical techniques such as Pringle maneuver (PM). Infrahepatic IVC clamping (IIVCC) is an alternative surgical technique to reduce central venous pressure and prevent retrograde hepatic venous bleeding. The aim of the meta-analysis was to compare IIVCC+PM with PMalone in terms of intraoperative outcomes and perioperative complications. Medline, Cochrane Library, Scopus, Web of Science, and EMBASE were searched for comparative studies till 16.04.2024, resulting in 679 articles, of which eight studies met inclusion criteria. Data on patient demographics, surgical technique, and perioperative outcomes was assessed. Cochrane Risk of Bias 2.0 (RoB 2.0) Tool and Newcastle-Ottawa Scale (NOS) were used for risk of bias assessment. Two randomized controlled trials, one prospective, and five retrospective cohort studies with 358 patients in IIVCC+PM and 397 patients in PMalone group were included. IIVCC+PM resulted in significantly greater CVP reduction, less intraoperative blood loss (MD (95% CI) = - 233.03 (- 360.48 to - 105.58), P < 0.001), and less intraoperative blood transfusion (OR (95% CI) = 0.38 (0.25 to 0.57), P < 0.001) compared to PMalone. The two groups had comparable total operative time, transection time and total intraoperative fluid infusion. Patients undergoing IIVCC+PM had significantly shorter length of stay (MD (95% CI) = - 0.63 days (- 1.21 to - 0.05 days), P = 0.03) and overall complication rates (OR (95% CI) = 0.63 (0.43-0.92), P = 0.02) compared to PMalone group. The utilization of IIVCC along with PM during liver resection may be beneficial in reducing intraoperative bleeding and blood transfusion without adversely influencing operative times or perioperative outcomes compared to PMalone.

Surgical management of renal cell carcinoma with subhepatic inferior vena cava tumor thrombus: a case report and review of the literature

BackgroundRenal cell carcinomas are the most common form of kidney cancer in adults. In addition to metastasizing in lungs, soft tissues, bones, and the liver, it also spreads locally. In 2–10% of patients, it causes a thrombus in the renal or inferior vena cava vein; in 1% of patients thrombus reaches the right atrium. Surgery is the only curative option, particularly for locally advanced disease. Despite the advancements in laparoscopic, robotic and endovascular techniques, for this group of patients, open surgery continues to be among the best options.Case reportHere we present a case of successful tumor thrombectomy from the infrahepatic inferior vena cava combined with renal vein amputation and nephrectomy. Our patient, a 58 year old Albanian woman presented to the doctors office with flank pain, weight loss, fever, high blood pressure, night sweats, and malaise. After a comprehensive assessment, which included urine analysis, complete blood count, electrolytes, renal and hepatic function tests, as well as ultrasonography and computed tomography, she was diagnosed with left kidney renal cell carcinoma involving the left renal vein and subhepatic inferior vena cava. After obtaining informed consent from the patient we scheduled her for surgery, which went well and without complications. She was discharged one week after to continue treatment with radiotherapy, chemotherapy, and immunotherapy.ConclusionOpen surgery is a safe and efficient way to treat renal cell carcinoma involving the renal vein and inferior vena cava. It is superior to other therapeutic modalities. When properly done it provides acceptable long time survival and good quality of life to patients.

Rescue From Permanent Kidney Injury in Acute Thrombosis of Both Renal Veins, the Inferior Vena Cava, and Both Iliofemoral Veins by Catheter-Based Thrombectomy.

A 33-year-old man with previously diagnosed lupus membranous nephropathy presented with painful swelling in both legs. Laboratory tests revealed acute kidney injury, and imaging studies by duplex ultrasound and computed tomography scan showed acute thrombosis of both renal veins, the infrahepatic inferior vena cava, and both iliofemoral venous segments. Initially, pharmacomechanical thrombolysis led to an insufficient morphological result. The therapeutic breakthrough was achieved by catheter-based mechanical thrombectomy of the infrarenal vena cava and both renal veins, which successfully cleared all affected venous segments from thrombus, paralleled by improvement of the patient's condition. However, after 1 week, the patient experienced recurrent thrombosis of the right renal vein with hemorrhagic infarction of the right kidney. After further optimization of immunomodulatory and antithrombotic therapy, a repeated catheter-based mechanical thrombectomy resulted in sustained clinical improvement and preservation of renal venous drainage and kidney function. Extensive acute thrombosis of both renal veins, the inferior vena cava, and both iliofemoral venous segments is a rare emergency potentially threatening kidney function. Immediate effective thrombus removal is essential to preserve kidney function and can be achieved by catheter-based mechanical thrombectomy embedded in a comprehensive immunomodulatory and antithrombotic therapeutic concept. This case demonstrated the efficacy of a catheter-based therapeutic approach in patients with extensive thrombosis of the venous system. A catheter-based approach must be embedded in a comprehensive medical therapeutic concept, which is essential to achieve a sustainable result.

Extensive Deep Vein Thrombosis: A Rare Manifestation of Disseminated Tuberculosis

A 20-Year-Old Male With Disseminated Tuberculosis (Pulmonary, Pleural, And Lymph Node TB) Presented With Unusual Manifestation In The Form Of Extensive Deep Vein Thrombosis (DVT) Involving Bilateral Popliteal Veins, Femoral Veins, Iliac Veins, And Infra-Hepatic Inferior Vena Cava (IVC). Upon Follow-Up With The Patient After Two Months Of Therapy, There Was A Significant Clinical Improvement, And Edema And Tenderness Of The Lower Limb Had Decreased.

Vascular Reconstruction with the Cuff Technique in Mouse Orthotopic Liver Transplantation.

Mouse orthotopic liver transplantation is an effective methodology for investigating the underlying mechanisms of liver ischemia and reperfusion injury. However, the technical challenges pose a barrier to utilizing this valuable experimental model and passing on these skills to the next generation. The most challenging aspect of this procedure is vascular reconstruction, including the portal vein (PV), infrahepatic inferior vena cava (IHIVC), and suprahepatic inferior vena cava. The use of plastic cuffs, rather than sutures, allows for smoother PV and IHIVC reconstruction. Vessels are reconstructed by attaching a cuff made from an intravenous catheter to the tip of the graft vessel and interposing the cuff into the recipient vessel. The two most crucial aspects are properly visualizing the inner lumen of the vessel and avoiding the use of excessive force. Our aim is to provide a technical overview of vascular reconstructions using the cuff technique in recipient surgery. These technical tips for the cuff technique are expected to help microsurgeons facilitate vascular reconstruction and advance their research.

Hepatic Glucose Production, Ureagenesis, and Lipolysis Quantified using the Perfused Mouse Liver Model.

The liver has numerous functions, including nutrient metabolism. In contrast to other in vitro and in vivo models of liver research, the isolated perfused liver allows the study of liver biology and metabolism in the whole liver with an intact hepatic architecture, separated from the influence of extra-hepatic factors. Liver perfusions were originally developed for rats, but the method has been adapted to mice as well. Here we describe a protocol for in situ perfusion of the mouse liver. The liver is perfused antegradely through the portal vein with oxygenated Krebs-Henseleit bicarbonate buffer, and the output is collected from the suprahepatic inferior vena cava with clamping of the infrahepatic inferior vena cava to close the circuit. Using this method, the direct hepatic effects of a test compound can be evaluated with a detailed time resolution. Liver function and viability are stable for at least 3 h, allowing the inclusion of internal controls in the same experiment. The experimental possibilities using this model are numerous and may infer insight into liver physiology and liver diseases.

743 Intraoperative Outcomes Using Infrahepatic Inferior Vena Cava Clamping During Hepatectomy: A Meta-Analysis

Abstract Aim The aim of this meta-analysis is to determine the effect of infrahepatic inferior vena cava clamping (IIVCC) with Pringle maneuver (PM) compared to only PM during hepatectomy on intraoperative outcomes. Method Medline, Cochrane Library, Scopus, Web of Science, and EMBASE were searched from inception till 23.11.2021 using a predefined search strategy. The initial search resulted in 615 unique articles. After screening, eight studies including 755 patients (358 in IIVCC+PM, 397 in PM group) met the inclusion criteria for this meta-analysis. Of these, two were randomized controlled trials, one prospective and five retrospective cohort studies. Data on patient demographics, surgical technique and intraoperative outcomes was collected. Summary estimates using the appropriate effect models were generated with Review Manager 5.0. Results Patients who underwent IIVCC + PM during hepatectomies experienced significantly less total intraoperative blood loss (mean difference (MD), 95% confidence interval (CI) = -233.03, -360.48 to -105.58; p = 0.0003), less blood loss during transection (MD, 95% CI = -172.91, -308.94 to -36.88; p = 0.01), and had significantly less intraoperative blood transfusion requirement (Odds ratio, 95% CI = 0.38, 0.25 to 0.57; p&amp;lt;0.0001) compared to patients who had only PM. Additionally, the total operative time was comparable between the two groups (MD, 95% CI = 8.06, 4.29 to 11.82; p&amp;lt;0.0001). There were no difference in the parenchymal transection time and total intraoperative fluid infusion between the two groups. Conclusions IIVCC + PM is beneficial in reducing intraoperative blood loss and need for transfusion without significantly affecting operative times in comparison to PM during hepatectomy.

Adrenocortical carcinoma with venous tumor invasion: is there a role for mini-invasive surgery?

This study aims to investigate early oncologic outcomes in patients with adrenocortical carcinoma (ACC) with venous invasion (VI) treated using both open and mini-invasive approaches. We conducted a retrospective analysis of 4 international referral center databases, including all the patients undergoing adrenalectomy for ACC with VI from January 2007 to March 2020. According to CT scan or MRI, the tumor thrombus was classified into four levels: (1) adrenal vein invasion; (2) renal vein invasion; (3) infra-hepatic Inferior vena cava (IVC); and (4) retro-hepatic IVC. In addition, we divided our patients into patients who had undergone open surgery and mini-invasive surgery. We identified 20 patients with a median follow-up of 12 months. The median tumor size was 110mm. ENSAT stage was II in 4 patients, III in 13 patients, and IV in 3 patients. Tumor thrombus extended in the adrenal vein (n=5), renal vein (n=1), infra-hepatic IVC (n=9), or into the retro-hepatic IVC (n=5). Ten patients were treated with a mini-invasive approach. The patient treated with an open approach reported a more aggressive disease. The two groups did not differ in surgical margins, surgical time, blood losses, complications, and length of stay. The prognosis resulted worse in the patient undergoing open. Kaplan-Meier analysis indicated a difference in OS for the patients stratified by ENSAT stage (Log-rank p=0.011); we also reported a difference in DFS for patients stratified for thrombus extension (p=0.004) and ENSAT stage (p<0.001). The DFS of patients with VI from ACC is influenced by the staging and the extension of the venous invasion; the staging influences the OS. The mini-invasive approach seems feasible in selected patients; however, further studies investigating the oncological outcomes are needed. A mini-invasive approach for adrenal tumors with venous invasion is an explorable option in very selected patients.

Abstract 12175: A Migrated External Iliac Stent - To Retrieve or Not to Retrieve

Endovascular venous stenting has become a more favorable intervention for occlusive, symptomatic deep vein thromboses (DVTs), especially given its decreased complication rate and shorter recovery time than its predecessor, open venous bypass. Risks, however, still exist and can include stent fragmentation and dislodgement causing cardiopulmonary complications. A 57-year-old man with bilateral lower extremity DVTs status post left external ilio-femoral stent and inferior vena cava (IVC) filter placement presented with one month of atypical chest discomfort. CT chest showed migration of his 40cm iliac stent to the IVC and right atrium. Interventional radiology visualized both a patent stent and IVC, however, attempted endovascular removal from the distal margin failed with initial retrieval of fragments only. Other fragments subsequently embolized to the pulmonary and lower lobe arteries and right ventricles. Extraction of more distal fragments was deferred due to risks of structural damage, arrhythmias, and pulmonary vasculature perforation. Fragment analysis by pathology demonstrated evidence of clot, yet cardiothoracic surgical intervention was deferred.The patient continued to experience chest pain and underwent a repeat CT chest three months later that demonstrated the stent extending from the right atrial junction to the infrahepatic IVC. Fragmented portions of the filter in the right ventricle and multiple stent fragments retained in the right upper and bilateral lower pulmonary lobes remained as prior with no evidence of pulmonary embolism (PE), pericardial effusion, or tamponade. Although rare, stent removal complications can occur with increased risk of long-term sequelae. Stent fracturing and dislodgement can result in foreign bodies showering the pulmonary vasculature and cardiac chambers, ultimately placing patients at risk for arterial perforation or dissection, pulmonary hemorrhage, intracardiac damage, tamponade, PE, and chronic thromboembolic pulmonary hypertension (CTEPH). The consideration of such risks, in addition to early involvement of interdisciplinary teams and thorough risk-benefit discussions between patients and providers are essential when undergoing stent removal and related interventions.

Preliminary experience of oblique occlusion technique in robot-assisted infrahepatic inferior vena cava thrombectomy: step-by-step procedures and short term outcomes

BackgroundWe aimed to compare the oncological outcomes between the oblique occlusion technique and the traditional technique for robot-assisted radical nephrectomy (RARN) with inferior vena cava (IVC) thrombectomy, and to explore the safety and effectiveness of the oblique occlusion technique.MethodsOverall, 21 patients with renal cell carcinoma (RCC) and IVC tumor thrombus (TT) were admitted to our hospital from August 2019 to June 2020. All the patients underwent RARN with IVC thrombectomy, of which the IVC oblique occlusion technique was used in 11 patients and traditional occlusion technique was used in 10 patients. The oblique occlusion technique refers to oblique blocking from the upper corner of the right renal vein to the lower corner of the left renal vein using a vessel tourniquet or a vessel clamp (left RCC with IVCTT as an example).ResultsCompared with patients in the traditional group, those in the oblique group had lower serum creatinine at follow-up (3 month) (95 ± 21.1 vs. 131 ± 30.7 μmol/L, P = 0.03). There was no significant difference in operation time [149 (IQR 143–245) min vs. 148 (IQR 108–261) min, p = 0.86], IVC clamping time [18 (IQR 12–20) min vs. 20 (IQR 14–23) min, p = 0.41], and estimated intraoperative blood loss [300 (IQR 100–800) mL vs. 500 (IQR 175–738) mL, p = 0.51] between both groups. During a 16-month (range, 15–23 months) follow-up period, two cases progressed in the oblique group and three cases progressed in the traditional group.ConclusionsThe modified IVC oblique occlusion technique procedure is relatively safe and effective in RARN with IVC thrombectomy. The IVC oblique occlusion technique may play a role in the protection of renal function.

Combined Transhepatic-Transsplenic Direct Intrahepatic Portocaval Shunt in a Child with Budd-Chiari Syndrome

A 6-year–old girl presented emergently with 3 episodes of hematemesis over 3 days and abdominal distension for 10 days. Physical examination revealed distended superficial abdominal veins. Ultrasonography (US) showed thrombosed hepatic veins and infrahepatic inferior vena cava (IVC) with ascites, which is diagnostic of chronic Budd-Chiari syndrome with portal hypertension. Direct intrahepatic portocaval shunt creation was planned under general anesthesia. Bilateral jugular and brachiocephalic veins were chronically occluded (Fig 1a), and femoral venography showed chronic occlusion of the IVC (Fig 1b).

Inferior Vena Cava (IVC) Resection Without Reconstruction for a Large IVC Leiomyosarcoma

BackgroundRetroperitoneal tumours arising from the inferior vena cava (IVC) are rare tumours often requiring large vessel resection for complete surgical excision. Limited exposure to such tumours often discourages surgeons from offering surgical resection to these patients, depriving them of the only potentially curative modality. We present here the surgical technique for resection of a large IVC sarcoma without IVC reconstruction. MethodsA 53-year-old lady presented with a large retroperitoneal sarcoma encasing the infra-hepatic IVC with tumour thrombus extension into the hepatic cloaca as well as the left renal vein. Surgical resection was planned as the disease remained stable after 2 cycles of neoadjuvant chemotherapy with adriamycin and ifosfamide. ResultsComplete surgical excision of the tumour was achieved by performing a resection of the entire length of infra-hepatic IVC and right kidney, without IVC reconstruction. Left renal vein was divided after careful preservation of a draining collateral. Tumour thrombus was extracted from the hepatic cloaca, and proximal IVC stump closure was achieved with preservation of right hepatic vein insertion. Total blood loss during the procedure was 2300 mL, and the patient recovered without compromise of renal function or development of lower limb oedema. ConclusionIVC resection without reconstruction can be safely performed for large retroperitoneal sarcomas involving major vascular structures. Familiarity with the retroperitoneal, retro-hepatic and supra-hepatic anatomy is paramount to achieving good surgical outcomes.

V13-06 OPEN RIGHT PARTIAL NEPHRECTOMY WITH INFERIOR VENA CAVA THROMBECTOMY FOR RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 May 2022V13-06 OPEN RIGHT PARTIAL NEPHRECTOMY WITH INFERIOR VENA CAVA THROMBECTOMY FOR RENAL CELL CARCINOMA Ryan Nasseri, Devin Patel, Daniel Holst, Margaret Meagher, and Ithaar Derweesh Ryan NasseriRyan Nasseri More articles by this author , Devin PatelDevin Patel More articles by this author , Daniel HolstDaniel Holst More articles by this author , Margaret MeagherMargaret Meagher More articles by this author , and Ithaar DerweeshIthaar Derweesh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002646.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We present a case of a 65 year-old female with cT3b renal cell carcinoma (RCC) and inferior vena cava (IVC) tumor thrombus who underwent open right partial nephrectomy (PN) with IVC thrombectomy at our institution. METHODS: 65 year-old female with CKD stage III [baseline estimated Glomerular Filtration Rate (eGFR) 57 ml/min.1.73m2] and active segmental pulmonary emboli (PE) presented with locally advanced RCC with venous tumor extension to the level of the intrahepatic IVC. Patient was deemed to not be optimal surgical candidate due to symptomatic PE and poor performance status (ECOG 2 status) and also had strong indication for nephron preservation. The patient ultimately underwent systemic therapy with 12 cycles of nivolumab and 6 cycles of ipilimumab with shrinkage of primary tumor and regression of tumor thrombus to the infrahepatic IVC. RESULTS: Open right PN with IVC thrombectomy was undertaken. A reverse-hockey stick incision was made. Large and small intestinal medial reflection was conducted with liver mobilization. Cranial and caudal IVC control was obtained as well as control of the contralateral renal vein. IVC clamping and control of the contralateral renal vein in addition to clamping of the main renal artery was conducted, and the tumor and IVC tumor extension were resected en bloc via a venotomy and longitudinal cavotomy, primary closure of which were performed with 6-0 and 3-0 Prolene. Collecting system entries and segmental vessels were closed with 3-0 Monocryl and 4-0 PDS. The cortical defect was then approximated with 0 Chromic suture and hemostatic agents.Final pathology demonstrated pT3b clear cell RCC/ISUP grade 2 with protrusion into IVC. Negative margins for primary tumor and distal caval margins. Postoperative creatinine was 1.01 ng/dL with eGFR of 55 mL/min/1.73m2. No evidence of disease was noted at 3-month radiologic follow up. CONCLUSIONS: PN with IVC thrombectomy may be safely achieved for select patient with imperative indication for nephron sparing surgery. Further investigation of long-term oncologic outcomes and efficacy are requisite. Source of Funding: Stephen Weissman Kidney Cancer Research Fund © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1032 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan Nasseri More articles by this author Devin Patel More articles by this author Daniel Holst More articles by this author Margaret Meagher More articles by this author Ithaar Derweesh More articles by this author Expand All Advertisement PDF DownloadLoading ...

Revival of an Old Technique

Piggyback orthotopic liver transplantation is mandatory when a patient can’t stand a vena cava clamping due to cardiac intolerance. If right and middle suprahepatic veins are separated (due to atrophic right liver and hypertrophic left liver), and cava clamping is not an option, performing the anastomosis with only the middle and left suprahepatic veins might end up in a reduced venous outflow and an acute Budd Chiari Syndrome could be developed. This scenery will end up with a graft failure. There is an old technique sometimes forgotten that can prevent this to happen described by Stieber in 1995: adding an anastomosis between the recipient’s preserved retrohepatic inferior vena cava and the donor infrahepatic inferior vena cava in an end to side fashion. We have performed this type of solution in 3 cases avoiding Budd Chiari syndrome and graft loss.

Infrahepatic Inferior Vena Cava Clamping Reduces Blood Loss during Liver Transection for Cholangiocarcinoma.

Background Major hepatectomy is the mainstay of the treatment for cholangiocarcinoma. Infrahepatic inferior vena cava (IVC) clamping is an effective maneuver for reducing blood loss during liver transection. The impact of this procedure on major hepatectomy for cholangiocarcinoma is unknown. This study evaluated the effect of infrahepatic IVC clamping on blood loss during liver transection. Methods Clinical and pathological data were collected retrospectively for 116 cholangiocarcinoma patients who underwent major hepatectomy between January 2015 and December 2016, to investigate the benefit of infrahepatic IVC clamping. Two of five surgeons adapted the policy performing infrahepatic IVC clamping during liver transection in all cases. Patients, therefore, were divided into those (n = 39; 33.6%) who received infrahepatic IVC clamping during liver transection (C1) and those (n = 77; 66.4%) who did not (C0). Results The patients' backgrounds, operative parameters, and extent of hepatectomy did not differ significantly between the 2 groups, except for gender. A significantly lower blood loss (p = 0.028), blood transfusion (p = 0.011), and rate of vascular inflow occlusion requirement (p < 0.001) were observed in the C1 group. The respective blood losses in the C1 group and the C0 group were 498.9 (95% CI: 375.8-622.1) and 685.6 (95% CI: 571-800.2) millilitres. Conclusions The current study found infrahepatic IVC clamping during liver transection for cholangiocarcinoma reduces blood loss, blood transfusion, and rate of vascular inflow occlusion requirement.

Not All Piggybacks Are Equal: A Retrospective Cohort Analysis of Variation in Anhepatic Transcaval Pressure Gradient and Acute Kidney Injury During Liver Transplant.

Complete inferior vena cava clamping in cavalreplacement during livertransplantis associated with substantial physiological derangement and postoperative morbidity. Partial clamping in the piggyback technique may be relatively protective, but evidence is lacking. Having observed substantial variation in transhepatic inferior vena cava pressure gradient with piggyback, we hypothesized that the causative mechanism is the extent of caval clamping rather than the surgical approach. We used internal jugular and femoral catheters to estimate suprahepatic and infrahepatic inferior vena cava pressures during clamping. Pressure gradients were calculated, and distributions were compared by surgical technique. We estimated adjusted odds ratios for pressure gradient on acute kidney injury at 72 hours. In 115 case records, we observed substantial variation in maximum pressure gradient; median values were 18.0 mm Hg(interquartile range, 8.0-25.0 mm Hg) with the piggyback technique and 24.0 mm Hg (interquartile range, 19.5-27.0 mm Hg) with caval replacement. Incidence of acute kidney injury was 25% (29 patients). Pressure gradient was linearly associated with probability of acute kidney injury (odds ratio, 1.06; 95% CI, 1.01-1.13). We report 2 novel findings. (1) Anhepatic inferior vena cavapressuregradient variedsubstantially in individuals undergoing piggyback, and (2) gradient was positively associatedwith early acute kidney injury. We hypothesize that this (unmeasured) variation explains the conflictingfindings ofprevious studies that compared surgical techniques. Also, we propose that caval pressure gradient could be routinely assessed to optimize real-time piggyback clamp position during livertransplant surgery.

Infrahepatic Inferior Vena Cava Clamping does not Increase the Risk of Pulmonary Embolism Following Hepatic Resection

BackgroundInfrahepatic inferior vena cava (IVC) clamping reduces central venous pressure. However, controversies remain regarding its impact on postoperative complications, particularly, the incidence of postoperative pulmonary embolism (PE). The aim of the study was to determine the impact of IVC clamping on the incidence of PE in patients undergoing hepatectomy.MethodsA pooled analysis of five prospective trials on patients who underwent hepatic resection over a period of 10 years was performed. Patients with infrahepatic IVC clamping were compared to patients without infrahepatic IVC clamping. Outcomes were studied by univariate and multivariate analyses.ResultsOf 505 included patients, 141 patients had IVC clamping and 364 patients served as control group. The rate of postoperative PE was comparable between groups (3% vs. 3%; P = 0.762), as were postoperative morbidity (P = 0.932), bile leakage (P = 0.272), posthepatectomy hemorrhage (P = 0.095), and posthepatectomy liver failure (P = 0.605), respectively. No clinicopathological and intraoperative risk factors were found to predict the onset of PE. Subgroup analyses of patients with major hepatectomy and vascular resections confirmed no adverse perioperative outcomes to be associated with IVC clamping.ConclusionsInfrahepatic IVC clamping does not increase the incidence of postoperative PE.

Efficacy and safety of infrahepatic inferior vena cava clamping under controlled central venous pressure for reducing blood loss during hepatectomy: A randomized controlled trial.

The purpose of this study was to evaluate the effectiveness and safety of inferior vena cava (IVC) clamping for reducing blood loss during hepatectomy. In total, 120 elective hepatectomy patients who underwent surgery from May 2016 to October 2017 were enrolled and randomized into the IVC clamping group or nonclamping group. Both groups were managed by anesthesiological techniques for CVP reduction. Blood loss and clinical parameters were analyzed for 30days after surgery. Fifty-nine patients were assigned to the IVC clamping group and 61 to the non-IVC clamping group. There was a significant difference in the total blood loss between both groups, with less blood loss observed in the IVC clamping group [500 vs 600mL, P=.006]. The transection blood loss in the IVC clamping group was also significantly lower than that in the non-IVC clamping group [300 vs 500mL, P<.001]. However, CVP was not associated with blood loss volume. Postoperative outcomes were not significant in either group. IVC clamping is beneficial for reducing blood loss during hepatectomy and is safe when combined with anesthesiological techniques. If feasible, this technique should be used regardless of the CVP value.

Evaluation of infrahepatic inferior vena cava clamping in robot-assisted laparoscopic liver resection

Objective: To evalutate the safety and efficacy of infrahepatic inferior vena cava clamping robot-assisted laparoscopic liver resection. Methods: All data about 24 patients with robotic liver resection at Hepatic Surgery Center,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology between February 2015 and December 2017 were collected and analyzed. These patients were divided into two groups based on different methods to decrease central venous pressure. Eight patients(6 males and 2 females,aged 49 years(range:50 to 56 years)) were applied with infrahepatic inferior vena cava clamping,and the other 16 matched cases (15 males and 1 female,aged 53 years(range:38 to 69 years)) were categorized into lowering central venous pressure group. Intraoperative blood loss,blood transfusion,intraoperative hemodynamic parameters,postoperative complications,and renal function were compared by t-test,non-parametric test,χ2 test,or Fisher exact test. Results: There was significantly difference in the intraoperative blood loss between the infrahepatic vena cava clamping group and the lowering central venous group(200(220) ml (range:100 to 400 ml) vs. 750(800) ml (range:100 to 2 000 ml),Z=‒2.169,P=0.030). The clamping time of portal triad and infrahepatic inferior vena cava were 24 (18) minutes and 29 (20) minutes in the infrahepatic inferior vena cava clamping group, and portal triad clamping time was 23 (23) minutes in the low central venous group. There was no significant difference between the two groups (Z=‒0.323, P=0.747). There was no intraoperative blood transfusion in the infrahepatic inferior vena cava clamping group, and 5 cases in the low central venous group, with a transfusion volume of 1.5(1.5)U. The difference between the two groups was statistically significant (Z=‒3.353, P=0.001). However, the mean arterial pressure in the infrahepatic vena cava clamping group decreased from (88.6±4.9) mmHg to (67.4±3.8) mmHg(1 mmHg=0.133 kPa), which was lower than that of lowering central venous group (72.4±3.3) mmHg (t=2.315,P=0.003). And there were no significant differences related to postoperative complications rate or hepatic and renal function in both groups. Conclusion: The infrahepatic inferior vena cava technology is safe and feasible to decrease central venous pressure during robotic liver resections,which will not affect the recovery of hepatic and renal functions.

High Complexity Major Liver Resection by Thunderbeat as a Sole Device under the Pringle Maneuver and Infra-Hepatic Inferior Vena Cava Clamping (With Video)

Introduction: In addition to conventional major or minor classification in liver resection (LR), recently, a complexity classification with 3 categories (low, medium, or high) according to its technical difficulty was proposed and validated. We describe the outcomes of high complexity major LR by Thunderbeat (TB) as a sole device under the Pringle maneuver and infra-hepatic inferior vena cava (IVC) clamping. Methods: Of 85 patients undergoing LR between July 2013 and November 2019, we reviewed seven patients who underwent this procedure. To evaluate the safety and rapidity, we compared the parenchymal transection time (PTT), estimated blood loss (EBL), and postoperative major complications (PMC) with nine patients who underwent medium or high complexity open major LR by the basic procedure, i.e. the clamp-crushing or the CUSA with supplemental use of energy devices. Results: Seven patients underwent extended right hepatectomy with hepaticojejunostomy (n=3), anatomical middle hepatectomy (n=2), and right trisectionectomy (n=1) or extended left hepatectomy (n=1) with IVC resection and reconstruction. Two patients experienced PMC (Clavien-Dindo classification IIIa: n=1, IIIb: n=1). There was no in-hospital mortality. Six patients are currently alive without recurrence with a median follow-up of 24 months. PTT [median (range)] in the TB group was significantly shorter: 19 (13-45) compared to 52 (18-174) min in the basic group (p=0.012). There was no significant difference in terms of EBL (p=0.918) and PMC (p=0.771). Conclusions: TB with the Pringle maneuver and infra-hepatic IVC clamping is feasible and may offer rapidity during high complexity major LR.