Replacement Of Inferior Vena Cava Research Articles

In vivo total or partial hepatectomy followed by ex vivo liver resection and autotransplantation for malignant tumors: a single center experience.

Ex vivo liver resection and autotransplantation (ELRAT) may provide an opportunity for R0 resection of conventionally unresectable hepatobiliary cancers and hepatic metastases. To date, few studies of the surgery for malignant tumors have been conducted and there are no known reports of in vivo partial hepatectomy followed by ELRAT (IPH-ELRAT) for malignant tumors. Between December 2021 and November 2022, ten patients with malignant hepatobiliary primary cancers or hepatic metastases underwent ELRAT at our institution. We shared the surgical skills and postoperative prognoses of these patients were assessed. The types of tumors were biliary tract cancer (BTC, n=8), hepatic metastasis of colonic carcinoma (n=1), and hepatic metastasis of small-bowel stromal tumor (n=1). Five patients underwent in vivo total hepatectomy followed by ex vivo liver resection and autotransplantation (ITH-ELRAT), The other five received in vivo partial hepatectomy followed by ex vivo liver resection and autotransplantation (IPH-ELRAT). Four patients underwent inferior vena cava replacement using artificial blood vessels. The survival rate of all ten patients one month after surgery was 100%. Nine patients (90%) are currently alive, with a median follow-up of 8.5 months (range 6-16.5 months). To date, seven of the nine surviving patients have had no cancer recurrence, including six with BTC. We report the world first five cases that received IPH-ELRAT for malignancies. We also demonstrated relatively favorable outcomes in patients who underwent ELRAT. ELRAT may be a recommendable surgical option for selected patients with conventionally unresectable hepatobiliary malignant tumors.

Reconstruction of Inferior Vena Cava by Autologous Great Saphenous Vein Grafts in Liver Surgery.

To secure surgical margin for hepatic lesion with involvement of the inferior vena cava (IVC), combined radical liver resection and IVC replacement are required. A novel method of replacing IVC by newly customized autologous great saphenous vein (GSV) grafts was introduced by this study. This study aimed at reporting the feasibility and outcome of this novel technique. From January 2014 to January 2021, all consecutive patients who underwent concomitant hepatectomy and IVC replacement by autogenous GSV graft were enrolled in this study. Technical insights, intraoperative details, demographic data, postoperative complication, graft patency and survival data were collected and analyzed. Concomitant hepatectomy/autotransplantation (ERAT) with IVC replacement by autogenous GSV graft was successful in 47 patients and there was no 30-day mortality. There were 8 out of the 47 patients whose retrohepatic venae cavae were completely invaded by the lesion and their reconstructed IVCs were totally made from GSV grafts. The other 39 patients whose IVCs were partially invaded had their IVCs reconstructed by both the unaffected part of the IVC wall and newly customized GSV graft. Postoperative complications classified as Clavien-Dindo grade II, III A and III B were observed in 10, 7 and 3 patients, respectively. The median follow-up months were 35months (29-80months). No patient developed thrombosis of the graft and 100% patency of the IVC was observed throughout the study. In selected patients, hepatectomy/ERAT with IVC replacement by autogenous GSV graft is safe and feasible. The newly customized autologous GVS graft was ideal for reconstruction of the IVC in liver surgery.

Future liver remnant augmentation preceding ex vivo hepatectomy with IVC replacement: a strategy to achieve R0 margins.

Ex vivo hepatectomy with autotransplantation (EHAT) provides opportunity for R0 resection. As EHAT outcomes after future liver remnant (FLR) augmentation techniques are not well documented, we examine results of EHAT after augmentation for malignant tumors. Retrospective analysis of six cases of EHAT was performed. Of these, four occurred after preoperative FLR augmentation between 2018 and 2022. Six patients were offered EHAT of 26 potential candidates. Indications for resection were involvement of hepatic vein outflow and inferior vena cava (IVC) with metastatic colorectal carcinoma (n = 3), cholangiocarcinoma (n = 2), or leiomyosarcoma (n = 1). Five patients were treated with neoadjuvant chemotherapy and four had preoperative liver augmentation. One hundred percent of cases achieved R0 resection. Of the augmented cases, three patients are alive after median follow-up of 28 months. Postoperative mortality due to liver failure was 25% (n = 1). For select patients with locally advanced tumors involving all hepatic veins and the IVC for whom conventional resection is not an option, EHAT provides opportunity for R0 resection. In addition, in patients with inadequate FLR volume, further operative candidacy with acceptable results can be achieved by combined liver augmentation techniques. To better characterize outcomes in this small subset, a registry is needed.

Nephrectomy with resection and replacement of inferior vena cava in a 1-year-old patient with nephroblastoma of the left kidney and thrombosis of inferior vena cava and right atrium

<h3></h3> Опухолевый тромбоз нижней полой вены и правого предсердия считают редким осложнением в детской солидной онкологии. Лечение таких пациентов сопряжено с высокими рисками осложнений и неблагоприятного исхода, что требует мультидисциплинарного подхода и использования высокотехнологичного оборудования на всех этапах комбинированного или комплексного лечения. На сегодняшний день не решен ряд вопросов, касающихся деталей оперативного вмешательства, подготовки пациентов к хирургическому лечению и наблюдения в послеоперационном периоде. В статье описан случай успешного хирургического лечения пациентки с нефробластомой левой почки и опухолевым тромбозом нижней полой вены и правого предсердия, а также представлен обзор актуальной литературы.

Inferior Vena Cava Reconstruction Using a Ringed Polytetrafluoroethylene Interposition Graft and Inferior Vena Cava Filter Placement Following Resection of Renal Cell Carcinoma With a Tumor Thrombus Directly Infiltrating the Inferior Vena Cava.

BackgroundRenal cell carcinoma (RCC) with tumor thrombus (TT) may extend into and, in rare cases, actually invade the inferior vena cava (IVC). Techniques of IVC reconstruction after removal of the RCC, TT, and infiltrated portion of the IVC have not been well documented. Methods A ringed polytetrafluoroethylene (PTFE) interposition graft along with an IVC filter placed within the graft (to prevent the development of pulmonary emboli) was used for patients who underwent surgical resection of RCC with TT extending into and directly invading the wall of the IVC. Demographic information about these patients along with their pathology reports, surgical procedures, and patency of the PTFE graft was obtained and described. Results Four male patients were identified as having RCC and TT with histologic invasion of the IVC requiring IVC dissection and replacement with a PTFE graft (as described above); their TT levels were II, IIIa, IIIc, and IV, respectively. Patient ages were 58, 65, 58, and 51years and tumor sizes were 7.5, 7.5, 15.0, and 6.5cm, respectively. These patients were followed for 36, 24, 32, and 48months, respectively. At last follow-up, each patient had a patent IVC graft, and none of them developed any pulmonary emboli post-operatively. Conclusions Ringed PTFE interposition graft along with an IVC filter deployed inside the graft appears to be a safe vascular conduit for IVC reconstruction after surgical resection of RCC with TT directly invading the IVC.

Living donor liver transplantation for hepatic malignancies in children.

Living donor liver transplantation is a treatment option for unresectable hepatic tumors in children. We enrolled 45 living donor transplantations performed between 1993 and 2018 for liver malignacies, which included hepatoblastoma (n=33), hepatocellular carcinoma (n=10), hepatic angiosarcoma (n=1), and rhabdomyosarcoma (n=1). No mortality or major morbidities were encountered in any donor, and the complication rate was 9%.In the hepatoblastoma group, 5-year overall and event-free survival rate in recipients was 87.4% and 75.8%, respectively, andmortality was significantly higher in patients after rescue transplantation (p=.001).Inferior vena cava replacement in these recipients appeared to be associated with reduced mortality (p=.034),but this was not confirmed when rescue patients were excluded (p=.629).In hepatocellular carcinoma group, both 5-year overall and event-free survival rates were 75.4% each, andinvasion of hepatic veins was significantly associated with increased risk of recurrence and death (p=.028).The patient with rhabdomyosarcoma died from EBV-induced lymphoma 2months after transplantation. The patient with angiosarcoma was in complete remission at the last follow-up.Overall, 5-year graft survival rate was 81.3%,and one patient underwent re-transplantation due to chronic rejection. Pediatric oncological liver transplantation has become a key player in the management of malignancies with cancer cure in 84% of patients in this series. Living donor liver transplantation for pediatric recipients with unresectable tumors might be a beneficial surgical option, which is technically safe for donors and recipients, thus, allowing timely planning according to chemotherapy protocols.

Living Donor Liver Transplant for Budd-Chiari Syndrome Without Caval Replacement: A Single-Center Study.

Adequate venous outflow is one of the most important factors responsible for optimal graft function in liver transplantation. Thrombosis of the inferior vena cava in cases of Budd-Chiari syndrome poses a major challenge to a transplant surgeon in establishing proper graft outflow. In deceased donor liver transplant, this problem can be dealt with relative ease as the liver graft includes donor inferior vena cava. However, this is not the case in living donor liver transplant. We present our findings of living donor liver transplant for Budd-Chiari syndrome and discuss techniques that have helped overcome this unique problem without the need for complete inferior vena cava replacement. Our retrospective analysis included living donor liver transplant recipients from November 2006 to March 2020 at our center and selected patients who underwent this transplant for Budd-Chiari syndrome. We studied the extent and severity of inferior vena cava involvement in these cases. We developed a classification that not only helped to stratify patterns of venacaval disease but also helped to plan the surgical technique. The role of interventional radiology combined with surgery in management of extensive inferior vena cava stenosis was studied. Among 2952 cases of liver transplant in our unit from November 2006 to March 2020, 36 patients had Budd-Chiari syndrome; 21 had significant level of inferior vena cava thrombosis, which was managed with inferior vena cava thrombectomy with either patchplasty (n = 20) or segmental replacement (n = 1). None of our patients showed recurrence of primary disease during the median follow-up of 36 months (range, 8-158 mo). Establishment of adequate venous ouflow in thrombosed inferior vena cava is possible with proper planning of surgical technique and timely involvement of interventional radiology-guided interventions in patients with Budd-Chiari syndrome.

Preoperative prediction score of hepatocellular carcinoma recurrence in living donor liver transplantation: Validation of SNAPP score developed at Asan Medical Center

Preoperative prediction score of hepatocellular carcinoma recurrence in living donor liver transplantation: Validation of SNAPP score developed at Asan Medical Center

V10-09 CHALLENGING RENAL CELL CARCINOMA CASES WITH INFERIOR VENA CAVA INVOLVEMENT: FROM EXTIRPATION TO CAVAL REPLACEMENT

You have accessJournal of UrologyAdrenal Surgery & Kidney Cancer II (Advanced Kidney Cancer & Vascular Reconstruction) (V10)1 Apr 2020V10-09 CHALLENGING RENAL CELL CARCINOMA CASES WITH INFERIOR VENA CAVA INVOLVEMENT: FROM EXTIRPATION TO CAVAL REPLACEMENT Kathryn Scott* and Gennady Bratslavsky Kathryn Scott*Kathryn Scott* More articles by this author and Gennady BratslavskyGennady Bratslavsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000935.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In this video presentation we describe three complex cases of renal cell carcinoma (RCC) with inferior vena cava (IVC) involvement managed robotically by a urologic oncologist. METHODS: Robotic assistance was used to treat three different cases of RCC with IVC involvement. In all 3 cases radical nephrectomy was performed and combined with IVC thrombectomy or resection with either IVC repair or replacement. The first case demonstrates a large right renal mass with an 11cm level III IVC thrombus. This was excised using robotic assistance and the IVC was primarily repaired. The second case demonstrates management of a large right renal mass invading into the liver and abdominal side wall and having an IVC thrombus. Using robotic assistance we performed partial hepatectomy (segment VI), IVC thrombectomy, radical nephrectomy, and abdominal wall resection in the order listed above. The final case demonstrates management of recurrent RCC after right partial nephrectomy 5 years prior to diagnosis with direct invasion of the IVC. A nephrectomy with IVC resection was performed. In this case the IVC is replaced with a vascular graft. RESULTS: All the presented cases were completed robotically by a single urologic oncologist. All patients were discharged to home 36-48 hours postoperatively. There were no perioperative complications. All patients are alive and have no local recurrence as of follow-up at 5, 1.5, and 1.5 years later, respectively. This video focuses on important technical aspects of each case. Important teaching points included stress the importance of mobilization of the caudate lobe via ligation of short hepatic veins, allowing IVC to back bleed during completion of the closure to avoid catastrophic events of clot or air embolus, management of the liver invasion, and IVC closure/replacement techniques. Additional technical caveats are highlighted during the narrative of this video presentation. CONCLUSIONS: Robotic assistance may expand the armamentarium for complex cases in urologic oncology allowing for benefits of a minimally invasive approach and minimizing hospital stay. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e933-e933 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kathryn Scott* More articles by this author Gennady Bratslavsky More articles by this author Expand All Advertisement PDF downloadLoading ...

Inferior vena cava resection and reconstruction for abdominal malignancies: Outcomes of limited resection versus IVC replacement

Background: Curative (R0) resection of abdominal malignancies with inferior vena cava (IVC) invasion or tumor thrombus often requires partial or circumferential caval resection. Reconstructive options frequently require multidisciplinary surgical support and are affected by location/extent of invasion, physiologic tolerance of vascular cross-clamping, and chronic occlusion of the distal IVC. Recent application of transplant techniques to accomplish ex-vivo liver resections have expanded the potential for curative resections in patients with previously unresectable malignant invasion of the retrohepatic IVC. This study aims to review the indications, techniques, and outcomes for IVC resection and reconstruction at a single institution. Methods: A retrospective review was conducted on patients with IVC resections for treatment of abdominal malignancies between 2008-2018 at a single institution. Demographics and cancer diagnoses were recorded, as well as operative approaches and reconstructive methods. Postoperative morbidity followed to 90 days after surgery and survival was tracked until death or loss to follow-up. Results: Of the 52 patients who underwent IVC repair for tumor invasion, 32 required a type of IVC wall resection. Of those that underwent wall resection, the most common malignancies were renal cell carcinoma (n = 17), intrahepatic cholangiocarcinoma (n = 4), leiomyosarcoma (n = 4), colorectal liver metastases (n = 2). One case occurred due to hepatocellular carcinoma, retroperitoneal liposarcoma, and metastatic disease from a pancreatic adenocarcinoma, gastrointestinal stromal tumor, and small bowel neuroendocrine tumor each. IVC reconstruction was performed through primary closure in 34% (11/32) or bovine pericardial patch in 25% (8/32) for partial wall resections, and synthetic graft in 25% (8/32) for circumferential resections. Five patients (16%) underwent ligation of the infrarenal IVC without reconstruction. Resection was performed on veno-venous cardiopulmonary bypass in 25% (8/32). Three patients underwent an ex-vivo partial hepatectomy with back-table IVC resection and reconstruction followed by liver auto-transplantation, including one case as stage II of an associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure. R0 resection was accomplished in 60% (3/5) for IVC ligation without reconstruction, 73% (8/11) for primary repair, and 63% (5/8) for bovine pericardial patch. Circumferential resection with synthetic graft reconstruction achieved R0 in 100% (8/8) including all three ex-vivo resections. Ninety-day major morbidity (Clavien grade 3 or greater) for IVC resections was 41% (13/32), with no increase for synthetic grafts compared to primary or patch repair (25% vs 37%, p = 0.55). Overall survival for IVC resections at 90 days, 1-year, and 2-years was 79%, 68%, and 64%, respectively. Conclusion: IVC resection with or without various techniques for reconstruction has an acceptable morbidity and provides the only opportunity for R0 resection in some locally-advanced abdominal malignancies. Circumferential resection with graft reconstruction (including ex-vivo for select patients) can achieve an excellent rate of R0 resection without increased morbidity. These complex reconstructions frequently require the technical acumen of hepatobiliary and transplant disciplines and should be performed in highly specialized centers with a multidisciplinary approach.

Ante-situ resection: a novel approach to minimize vascular exclusion complications

Background: Ex-vivo techniques provide excellent accessibility to hepatic tumours located around the inferior vena cava (IVC) that otherwise would be unresectable. These techniques usually require long-duration vascular exclusion or a veno-venous bypass. A novel technique in ante-situ resection to avoid the extracorporeal bypass using an in-vivo veno-venous bypass between the portal vein and the IVC with a cadaveric venous graft in a patient with IVC replacement is described. Methods: Recurrent colorectal liver metastases in a 27-year-old female with a previous right hepatic trisectionectomy. The lesion compromised the hepatocaval confluence and the only remaining hepatic vein. Results: A shunt between the infrahepatic IVC and the portal vein, using a bank-preserved cadaveric vein graft was performed, achieving a side-to-side porta-caval shunt. The IVC was replaced by a prosthetic graft. With the liver in an ante-situ position, cooled with ice and with the hypothermic preservation solution, the tumour resection was performed involving retrohepatic IVC and the confluence with the left hepatic vein. After resection and vascular reconstruction were completed( with a cadaveric bank preserved vein placed between the goretex graft and the remaining hepatic vein), the portal cannula was removed, and the portacaval shunt divided using staplers. Conclusion: With this novel technique we were able to avoid splanchnic congestion or a extracorporeal veno-venous bypass in an ante-situ liver resection.

Ante-Situ Resection: A Novel approach to minimize vascular exclusion complications

Background: Ex-vivo techniques provide excellent accessibility to hepatic tumours located around the inferior vena cava (IVC) that otherwise would be unresectable. These techniques usually require long-duration vascular exclusion or a veno-venous bypass. A novel technique in ante-situ resection to avoid the extracorporeal bypass using an in-vivo veno-venous bypass between the portal vein and the IVC with a cadaveric venous graft in a patient with IVC replacement is described. Methods: Recurrent colorectal liver metastases in a 27-year-old female with a previous right hepatic trisectionectomy. The lesion compromised the hepatocaval confluence and the only remaining hepatic vein. Results: A shunt between the infrahepatic IVC and the portal vein, using a bank-preserved cadaveric vein graft was performed, achieving a side-to-side porta-caval shunt. The IVC was replaced by a prosthetic graft. With the liver in an ante-situ position, cooled with ice and with the hypothermic preservation solution, the tumour resection was performed involving retrohepatic IVC and the confluence with the left hepatic vein. After resection and vascular reconstruction were completed (with a cadaveric bank preserved vein placed between the goretex graft and the remaining hepatic vein), the portal cannula was removed, and the portacaval shunt divided using staplers. Conclusion: With this novel technique we were able to avoid splanchnic congestion or a extracorporeal veno-venous bypass in an ante-situ liver resection.

Intrahepatic cholangiocarcinoma followed by vascular invasion: is surgical treatment justified?

To analyze safety of advanced liver resections combined with great vessels repair for locally advanced large and multiple cholangiocellular carcinoma. Since January 2014 till April 2017 eighty ICC patients have undergone advanced liver resection. There were 62 patients with portal cholangiocarcinoma and 18 with ICC. 4 ICC patients required vascular repair: IVC replacement in 2 cases (i.e. under venous bypass in 1 of them), tangential and circular resection of portal vein bifurcation - in 2 cases. Postoperative complications Clavien-Dindo IIIa developed in all cases. There were no vascular complications. The length of hospital-stay was 14 - 35 days. There were no lethal outcomes. Annual survival was 50%, 2-year - 25%. Adjuvant chemotherapy was used in all patients. Advanced liver resection followed by IVC and PV repair for locally advanced ICC may be safely performed and subsequently allows chemotherapeutic treatment.

Surgical management of liver diseases invading the hepatocaval confluence based on IH classification: The surgical guideline in our center.

AIMto investigate the short-term outcomes and risk factors indicating postoperative death of patients with lesions adjacent to the hepatocaval confluence.METHODSWe retrospectively analyzed 54 consecutive patients who underwent hepatectomy combined with inferior vena cava (IVC) and/or hepatic vein reconstruction (HVR) from January 2012 to January 2016 at our liver surgery center. The patients were divided into 5 groups according to the range of IVC and hepatic vein involvement. The patient details, indications for surgery, operative techniques, intra- and postoperative outcomes were compared among the 5 groups. Univariate and multivariate analyses were performed to explore factors predictive of overall operative death.RESULTSIVC replacement was carried out in 37 (68.5%) patients and HVR in 17 (31.5%) patients. Type I2H2 had the longest operative blood loss, operative duration and overall liver ischemic time (all, P < 0.05). Three patients of Type I3H1 with totally occluded IVC did not need IVC reconstruction. Total postoperative morbidity rate was 40.7% (22 patients) and the operative mortality rate was 16.7% (9 patients). Factors predictive of operative death included IVC replacement (P = 0.048), duration of liver ischemia (P = 0.005) and preoperative liver function being Child-Pugh B (P = 0.025).CONCLUSIONIVC replacement, duration of liver ischemia and preoperative poor liver function were risk factors predictive of postoperative death. We should be cautious about IVC replacement, especially in Type I2H2. For Type I3H1, it was unnecessary to replace IVC when the collateral circulation was established.

Surgical outcomes of hepatocellular carcinoma invading hepatocaval confluence

Combined liver and inferior vena cava (IVC) resection followed by IVC and/or hepatic vein reconstruction (HVR) is a curative operation for selected patients with hepatocellular carcinoma (HCC) invading the hepatocaval confluence. The present study aimed to elucidate the prognostic factors for patients with HCC invading the hepatocaval confluence. Forty-two consecutive patients underwent hepatectomy, combined with IVC replacement and/or HVR for HCC between January 2009 and December 2014 were included in this study. The cases were divided into three groups based on the surgical approaches of HVR: group 1 (n=13), tumor invaded the hepatocaval confluence but with one or two hepatic veins intact in the residual liver, thus only the replacement of IVC, not HVR; group 2 (n=23), the hepatic vein of the residual liver was also partially invaded, and the hepatic vein defect was repaired with patches locally; group 3 (n=6), three hepatic veins at the hepatocaval confluence were infiltrated, and the hepatic vein remnant was re-implanted onto the side of the tube graft. The patient characteristics, intra- and postoperative results, and long-term overall survival were compared among the three groups. The survival-related factors were analyzed by univariate and multivariate analysis. The group 1 had higher preoperative alpha-fetoprotein level (P<0.001), shorter operation time, hepatic ischemic time and hospital stay compared with groups 2 and 3 (P<0.05). The 1-, 3-, and 4-year overall survival rates of group 1 were 84.6%, 23.1% and 23.1%, respectively; group 2 were 78.3%, 8.7% and 8.7% respectively and group 3 were 83.3%, 0 and 0, respectively. The multivariate analysis showed that the independent poor prognostic factors of overall survival were preoperative higher HBV DNA level (≥103 copies/mL; P=0.001), tumor size (≥9 cm; P<0.0001), age (≥60 years; P=0.010) and underwent HVR (P<0.0001). Patients with reconstructing hepatic vein with patches locally (group 2) or to the artificial graft (group 3) had worse long-term survival than those without HVR (group 1). HVR was one of the unfavorable prognostic factors of overall survival.

The Use of Autologous Peritoneum for Complete Caval Replacement Following Resection of Major Intra-abdominal Malignancies.

Assessment of a simple layer peritoneal tube used as an autogenous inferior vena cava replacement. Extensive en-bloc multivisceral resection including major vessels is effective in selected abdominal malignancies, but the need for vascular reconstruction represents a surgical challenge. We describe the use of autologous peritoneum for caval replacement. Autogenous parietal peritoneum without fascial backing was harvested and tubularized to replace the inferior vena cava (IVC) in four patients with complex abdominal tumors. Surgical morbidity was evaluated using the Clavien-Dindo classification, and graft patency was systematically evaluated with ultrasound. All four patients had multiorgan resections for malignancies involving the retro-hepatic IVC, and they all required the replacement of infrarenal and suprarenal IVC segments. Additionally, all four required a right nephrectomy, two had a combined major hepatectomy, and one patient needed a veno-venous bypass. All had an R0 resection. A clinical follow-up took place between 5 and 11months after surgery for each patient. Four-month graft patency was confirmed by ultra-sound and TDM with no sign of disease recurrence. Autologous peritoneum without fascial backing is a good and safe option for circumferential replacement of IVC after extensive en-bloc tumor resection with IVC involvement.

Hepatic Venous and Inferior Vena Cava Morphology No Longer a Barrier to Living Donor Liver Transplantation for Budd-Chiari Syndrome: Surgical Techniques and Outcomes.

Living donor liver transplantation (LDLT) for Budd-Chiari syndrome (BCS) has been reported with<10 inferior vena cava (IVC) replacements with vascular/synthetic graft. The goal of this study was to review outcomes of LDLT for BCS at our center, with an emphasis on surgical techniques and postoperative anticoagulation therapy. Between October 2011 and December 2015, a total of 1027 LDLTs were performed. Nine of these patients had BCS. We analyzed their etiologies, operative details, postoperative complications, and outcomes. The indication was chronic liver disease for all patients. Two patients required retrohepatic IVC replacement with a polytetrafluoroethylene graft due to severe adhesions and thrombosis, respectively. One patient required V-Y plasty for suprahepatic IVC narrowing. Five patients had portal venous thrombosis, 3 treated by thrombectomy, and 1 by renoportal anastomosis. The mean follow-up time was 18 ± 16 months. Only 1 early death occurred due to sepsis. The anticoagulation therapy involved heparin infusion from postoperative day 1, conversion to low-molecular-weight-heparin on postoperative days 3 to 6, followed by warfarin (postoperative days 9-16 to maintain an international normalized ratio of 2-3 long term), along with low-dose aspirin for 6 months. There was no recurrence of thrombosis. LDLT for BCS is well documented in literature. Prevention of recurrent thrombosis depends on meticulous surgical technique, perfect and wide outflow anastomoses, and a strict anticoagulation protocol. A synthetic (polytetrafluoroethylene) graft for IVC interposition is a safe and feasible option for reconstruction with good results. Low-dose aspirin with low-molecular-weight-heparin later converted to warfarin provides excellent results and prevents recurrence of thrombosis.

Our panel of experts highlight the most important research articles across the spectrum of topics relevant to the field of regenerative medicine.

Regenerative MedicineVol. 11, No. 2 Research HighlightsOur panel of experts highlight the most important research articles across the spectrum of topics relevant to the field of regenerative medicineThomas Bollenbach, Jizeng Qiao & Amber Kerstetter-FogleThomas Bollenbach Research & Development, Harvard Apparatus Regenerative Technology, 84 October Hill Road, Holliston, MA 01746, USASearch for more papers by this author, Jizeng Qiao Organogenesis, Inc., 150 Dan Rd, Canton, MA 02021, USASearch for more papers by this author & Amber Kerstetter-Fogle Case Western Reserve University, Cleveland, OH, USASearch for more papers by this authorPublished Online:29 Feb 2016https://doi.org/10.2217/rme.16.2AboutSectionsView ArticleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInReddit View articleReferences1 Hiki N, Nunobe S, Kubota T et al. Function-preserving gastrectomy for early gastric cancer. Ann. Surg. Oncol. 20, 2683–2692 (2013).Crossref, Medline, Google Scholar2 Watanabe M, Shin'oka T, Tohyama S et al. Tissue-engineered vascular autograft: inferior vena cava replacement in a dog model. Tissue Eng. 7, 429–439 (2001).Crossref, Medline, CAS, Google Scholar3 Nigam SK, Wu W, Bush KT. In vitro kidney development, tissue engineering and systems biology. Organogenesis 4(3), 137–143 (2008).Crossref, Medline, Google Scholar4 Grobstein C. Trans-filter induction of tubules in mouse metanephrogenic mesenchyme. Exp. Cell Res. 10, 424–440 (1956).Crossref, Medline, CAS, Google Scholar5 Herzlinger D, Qiao J, Cohen D, Ramakrishna N, Brown AMC. Induction of kidney epithelial morphogenesis by cells expression Wnt-1. Dev. Biol. 166, 815–818 (1994).Crossref, Medline, CAS, Google Scholar6 Qiao J, Cohen D, Herzlinger D. The metanephric blastema differentiates into collecting system and nephron epithelial in vitro. Development 121, 3207–3214 (1995).Crossref, Medline, CAS, Google Scholar7 Qiao J, Sakurai H, Nigam SK. Branching morphogenesis independent of mesenchymal–epithelial contact in the developing kidney. Proc. Natl Acad. Sci. USA 96, 7330–7335 (1999).Crossref, Medline, CAS, Google Scholar8 Rosines E, Sampogna RV, Johkura K et al. Staged in vitro reconstitution and implantation of engineered rat kidney tissue. Proc. Natl Acad. Sci. USA 104, 20938–20943 (2007).Crossref, Medline, CAS, Google Scholar9 Song B, Smink AM, Hones CV et al. The directed differentiation of human iPS cells into kidney podocytes. PLoS ONE 7(9), e4645 (2012).Crossref, Google Scholar10 Xia Y, Nivet E, Sanchi-Martinez I et al. Directed differentiation of human pluripotent cells to ureteric bud kidney progenitor-like cells. Nat. Cell Biol. 15(12), 1507–1515 (2013).Crossref, Medline, CAS, Google Scholar11 Narayanan K, Schumacher KM, Tasnim F et al. Human embryonic stem cells differentiate into functional renal proximal tubular-like cells. Kidney Int. 83, 593–603 (2013).Crossref, Medline, CAS, Google Scholar12 Takasato M, Er PX, Becroft M et al. Directing human embryonic stem cell differentiation towards a renal lineage generates a self-organizing kidney. Nat. Cell Biol. 16, 118–126 (2014).Crossref, Medline, CAS, Google Scholar13 Araoka T, Mae S, Kurose Y et al. Efficient and rapid induction of human iPSCs/ESCs into nephrogenic intermediate mesoderm using small molecule-based differentiation methods. PLoS ONE 9(1), e84881 (2014).Crossref, Medline, Google Scholar14 Xinaris C, Benedetti V, Rizzo P et al. In vivo maturation of functional renal organoids formed from embryonic cell suspensions. J. Am. Soc. Nephrol. 23, 1857–1868 (2012).Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Vol. 11, No. 2 Follow us on social media for the latest updates Metrics Downloaded 190 times History Published online 29 February 2016 Published in print March 2016 Information© Future Medicine LtdFinancial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.PDF download

Living Donor Liver Transplantation With Vena Cava Replacement

ObjectivesThis study sought to evaluate the indications, techniques, and results of inferior vena cava (IVC) replacement at living donor liver transplantation (LDLT). Materials and MethodsWe performed 821 LDLTs and 11 (1.3%) patients required concomitant IVC replacement. We analyzed the indications, replacement materials, and outcomes. ResultsRight, left, and left lateral liver lobes were transplanted in 7, 2, and 2 patients, respectively. The indications for IVC replacement were thrombosis/fibrosis in 7 patients (Budd-Chiari 4, hereditary tyrosinemia 1, congenital hepatic fibrosis 1, cryptogenic 1), involvement with mass in 3 patients (Echinococcus alveolaris 2, hepatoblastoma 1) and iatrogenic narrowing at IVC in 1 patient. Cryopreserved grafts (aorta n = 5, IVC n = 4, iliac vein n = 1) or synthetic graft (n = 1) were used for replacements. In 1 patient, hepatic outflow obstruction developed at 39 days and was treated successfully by interventional radiology. There was only 1 hospital mortality (8.9%) that was unrelated to caval replacement (subarachnoid hemorrhage). Of the remaining patients, the caval grafts were patent after a mean 7.7 months of follow-up (range 1 to 17 months). ConclusionsAlthough rare, IVC replacement can be necessary at LDLT. Budd-Chiari and E. alveolaris are the main underlying diseases for replacement requirements. Caval replacement with cryopreserved vascular grafts can provide successful short-term and long-term patency.

Ante-situm resection: a novel approach to avoid extracorporeal circulation using a transient portacaval shunt

Hepatic tumours located at the hepatocaval confluence or compromising the inferior vena cava (IVC) are not often resectable using conventional techniques. To overcome this problem, different surgical procedures have been described. Ex-vivo resection techniques provide excellent accessibility to tumours placed around the IVC that otherwise would be unresectable. These ex-vivo techniques include in-situ, ante-situm and ex-situ resections. The in-situ technique performs hypothermic perfusion of the liver, with cross-clamping but without sectioning of the vena cava and the hepatic pedicle. The ante-situm approach also includes hypothermic perfusion, with cross-clamping of the major vessels and division of the suprahepatic IVC for complete exposure of the liver, preserving the hepatic artery and biliary tree. And finally, the ex-situ technique requires cross-clamping and division of the major vessels for complete removal of the liver, allowing a bench procedure before re-implantation of the organ. The two main problems regarding ex-vivo procedures are the low hepatic tolerance to warm ischaemia and the splanchnic congestion secondary to vascular exclusion. Hypothermic hepatic perfusion and veno-venous bypasses, frequently used in classic ex-vivo resections, are two well-known strategies to avoid these complications. This report describes a novel technique of ante-situm resection using an in-vivo veno-venous bypass between the portal vein and the IVC with a cadaveric venous graft in a patient with IVC replacement. Case