Retrohepatic Inferior Vena Cava Research Articles

Resection of retrohepatic inferior vena cava without reconstruction in ex vivo liver resection and autotransplantation: a retrospective study

BackgroundRetrohepatic inferior vena cava (RIVC) resection without reconstruction in ex vivo liver resection and autotransplantation (ERAT) for advanced alveolar echinococcosis (HAE) is unclear.MethodsThis is a retrospective study of consecutive patients referred to our hospital from 2014 to 2018. Depending on the presence of a rich collateral circulation and stable blood volume in ERAT, patients did not rebuild the RIVC. Then, patients were selected some appropriate revascularization techniques for the hepatic and renal veins. Finally, all ERAT procedures were completed, and short- and long-term outcomes were observed.ResultsFive advanced HAE patients underwent ERAT without RIVC reconstruction. One patient died of circulatory failure 1 day after surgery. Another four patients, with a median follow-up duration of 18 months (range, 10–25 months), demonstrated normal liver and kidney function, no thrombosis and no HAE recurrence.ConclusionsThrough the long-term results of ERAT, the pros and cons of not reconstructing the RIVC need to be re-examined. In cases with a rich collateral circulation, the RIVC cannot be reconstructed. However, in cases requiring the resection of multiple organs, RIVC without reconstruction was prudential.

Ex vivo resection and temporary portocaval shunt of unresectable hepatocellular carcinoma followed by autotransplantation of liver: a case report

BackgroundEx situ liver resection and autotransplantation is among the most advanced techniques which has been introduced in recent years.Case presentationA 24-year-old male referred with chief complaints of abdominal pain, nausea, and vomiting from 1 month prior to admission. Computed tomography showed a large liver mass in the left lobe of the liver with involvement of retrohepatic inferior vena cava (IVC), in favor of hepatocellular carcinoma.After hepatectomy, the common bile duct was completely removed. A 4-cm Dacron graft was anastomosed to the inferior and top of the IVC. A temporary portocaval shunt was placed, and ex situ resection of the left lobe of the liver was done. Remnant of the liver was implanted. Reconstruction of the bile duct was done using a Roux-en-Y technique, and autotransplantation of the liver was then completed. During a 4-year follow-up, the patient had no complaints and is in good conditions.ConclusionWith appropriate consideration of patients, despite surgical complexities, ex situ resection of unresectable HCC can provide excellent prognosis.

Modeling variability in the inferior vena cava into fenestrated endografts for retrohepatic caval injuries

ObjectiveInjury of the retrohepatic inferior vena cava (IVC) is rare, but extremely fatal. Open repair of these injuries is challenging. Various maneuvers, including atriocaval shunting and total vascular isolation, have been described, but are poorly tolerated in the severely injured patient. Endovascular repair is an attractive alternative strategy, but effective hemostasis of complex injuries requires an endograft that excludes the injury while permitting flow from the hepatic veins. Unfortunately, IVC and hepatic vein anatomy is highly variable and has not been clearly described in injured patients. Our purpose was to characterize critical human IVC morphology in trauma patients, and develop the design parameters of an off-the-shelf fenestrated endograft intended for caval deployment. MethodsOne hundred consecutive adult trauma patients with an admission computed tomography scan including a portal venous phase of the abdomen were reviewed. Specific anatomic measurements including segmental IVC lengths and diameters were obtained. Multiple theoretical endografts were modeled to optimize caval coverage in the retrohepatic segment, assuming 10% to 40% oversizing for seal. ResultsThis sample population had a mean age of 50 years, height of 173 cm, and weight 84 kg. Seventy-one percent were male and 89% had a blunt mechanism of injury. The median caval length from the renal veins to right atrium was 111 mm (interquartile range [IQR], 102-120 mm), diameter was 22 mm (IQR, 19-26 mm), and hepatic venous orifice area was 336 mm2 (IQR, 267-432 mm2). All patients had a landing zone of at least 12 mm in the suprahepatic and 10 mm in the suprarenal segments. Three models of graft length were developed to accommodate patients with segmental and overall dimensions in the smallest half, third quartile, and fourth quartile. These could provide 95% of patients with coverage of the retrohepatic segment without risk of hepatic or renal vein occlusion. Four graft diameters were developed for cross-sectional fit. Graft diameters of 20, 24, 30, and 38 mm could provide adequate coverage in, respectively, 11%, 35%, 49%, and 16% of patients. These combinations of graft length and diameter would accommodate 93% of patients. ConclusionsWe defined human IVC morphology essential for endovascular therapy and developed parameters for fenestrated IVC endografts to address retrohepatic caval injuries in trauma patients. Although additional study and testing are required, this proof-of-concept study supports the hypothesis that exclusion of the most devastating retrohepatic IVC injuries can be achieved with a reasonable number of off-the-shelf fenestrated endografts. These findings form the basis for additional research toward the development of novel devices for endovascular therapy of these often lethal injuries.

Clinical application of isolated hepatectomy with preservation of retrohepatic inferior vena cava and autologous liver transplantation in treating end-stage alveolar hepatic hydatid disease

探讨保留肝后下腔静脉的离体肝切除、自体肝移植术在治疗终末期肝泡型包虫病中的疗效。回顾性分析青海省人民医院包虫诊疗中心自2017年1月至2019年3月收治的3例行保留肝后下腔静脉的离体肝切除、自体肝移植术的肝泡型包虫患者临床资料。术中2例患者肝后下腔静脉从包虫病灶完整剥离，未行肝后下腔静脉搭桥、重建。1例患者在离体包虫病灶切除时完整保留肝后下腔静脉，未行人工血管重建肝后下腔静脉。术后3例患者出现不同类型并发症，经积极处理后顺利出院。出院后随访2～18个月，3例患者均无血栓并发症，其中1例患者健肝再发包虫，2例患者肝再生良好、无包虫复发。保留肝后下腔静脉的离体肝切除、自体肝移植术在治疗终末期肝泡型包虫病在本研究中疗效较好。

Liver Transplantation Using Right Lobe Graft With Focal Nodular Hyperplasia: Report of 2 Cases

We described 2 cases of adult-to-adult liver transplantation using right lobe grafts donated by 2 patients suffering from focal nodular hyperplasia, the volumes of which were 360 cm3 and 220 cm3. This study was performed in compliance with the Declaration of the Helsinki. For preparation of the graft, back-table hepatic venous outflow reconstruction, including replacement of the retrohepatic inferior vena cava and bridging of hepatic segment V5/V8, was performed by using prosthetic vessel grafts. The liver grafts after subtracting the weight of focal nodular hyperplasia functioned well without serious small-for-size syndrome or graft dysfunction in spite of graft-to-recipient weight ratio less than 0.8%. This suggested the functioning of hepatocyte within focal nodular hyperplasia, which avoided graft deficiency. These 2 recipients were given not only conventional immunosuppressants (tacrolimus and mycophenolate sodium) but also anticoagulants (low molecular weight heparin and warfarin). Thrombosis of the prosthetic inferior vena cava 1 month after transplant in recipient 1 was treated by placement of intravascular stent. Biliary duct anastomotic stricture 2 weeks after transplant in recipient 2 was treated by placement of biliary stent. These 2 recipients remain well at more than 2 years post-transplant. These successful explorative cases highlight the safe use of a graft containing focal nodular hyperplasia. The partial liver resection grafts with focal nodular hyperplasia could be applied to the patients on the waiting list for liver transplantation.

Resection of the Dorsal Sector of the Liver: The Anterior Transhepatic Approach

As defined by Couinaud et al. and Takasaki et al., the dorsal sector (DS) or caudate area is the portion of liver parenchyma located between the retrohepatic inferior vena cava (IVC) and the main hepatic veins confluence.1,2 Its complete resection, usually approached by right- or left-sided liver parenchymotomy, remains technically challenging.3,4 Moreover, these approaches usually fail to properly expose the middle (paracaval portion) and most cranial portion (i.e. behind the hepatic vein confluence) of the DS.5 METHODS: We report the case of a 50-year-old woman presenting with a unique metachronous hepatic metastasis of a colorectal adenocarcinoma. The 40-mm lesion was located behind the confluence of the three main hepatic veins, in front of the IVC, and extended caudally behind the hepatic hilum, thereby occupying the paracaval portion of the DS. The tumor board decision was surgical resection. The procedure included complete anatomic resection of the DS using an anterior transhepatic approach by opening the liver midplane along the Cantlie line. A well-tolerated continuous pedicle and IVC clamping of 30min was used. The duration of the surgery was 120min, and the blood loss was 200mL. The patient was discharged on postoperative day 5. R0 resection was achieved and the patient was free of disease at 1year post-surgery. Anatomic resection of the DS using a transparenchymal anterior approach is a safe and feasible procedure especially suitable for voluminous tumors. It allows the control of all major vascular structures narrowing the lesion, and facilitates an R0 resection.

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.

Outcomes of different surgical resection techniques for end-stage hepatic alveolar echinococcosis with inferior vena cava invasion

BackgroundHepatic alveolar echinococcosis (HAE) lesions with inferior vena cava (IVC) invasion require combined resection of the liver and IVC. The outcomes of different surgical treatments, including in situ, ante situm and ex vivo resection, remain unclear. MethodsA total of 71 consecutive HAE patients who underwent hepatectomy with retrohepatic IVC resection were included. The patients were divided into ex vivo liver resection and autotransplantation (ERAT) group (n = 45) and in vivo resection group (n = 26). These techniques were assessed for feasibility and short- and long-term outcomes. ResultsThere were no significant differences with respect to postoperative complications and mortality between the ERAT and in vivo resection groups. The causes of mortality were liver failure in 3 patients, hemorrhagic shock in 1 patient, intra-abdominal bleeding in 1 patient, and acute cerebral hemorrhage in 1 patient. During a median of 22 months followed-up time, 2 patients developed ascites because of venous outflow stenosis, and 1 patient developed biliary stenosis in the ERAT group. The distant metastasis, local recurrence, and mortality rates were 0%, 1.4%, and 8.5%, respectively. ConclusionCombined liver resection and reconstruction of the IVC can be safely performed in selected patients with in situ, ante situm, and ex vivo resection.

Comparison of Open Versus Robotic Nephrectomy and Inferior Vena Cava Reconstruction for Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus

Vascular surgeons are frequently involved in inferior vena cava (IVC) reconstruction during nephrectomy for renal cell carcinoma (RCC) with tumor thrombus. Robotic nephrectomy for RCC claims shorter length of stay (LoS), faster return to work, and decreased pain medication requirements. Our goal was to compare our robotic nephrectomy with IVC reconstruction experience with our open experience. We performed a single-institution retrospective review of patients undergoing open or robotic nephrectomy for RCC with IVC tumor thrombus between January 1998 and January 2018. Patients’ characteristics, surgical records, and follow-up and survival data were recorded. Tumor level was classified according to the Mayo Clinic venous tumor thrombus (VTT) level. There were 57 patients (49 male) who underwent nephrectomy with tumor thrombectomy and IVC reconstruction; 38 (66%) had open procedures for RCC with level 1 (n = 6), level 2 (n = 21), and level 3 (n = 11) VTT. Average operative time was 251 minutes (range, 108-375 minutes), and average blood loss was 2482 mL (range, 50-10,950 mL). Average LoS was 10.79 days (range, 1-95 days). There were two (3.5%) deaths within 30 days. Short-term complications included atrial fibrillation (n = 2), ileus (n = 2), seroma (n = 1), sepsis (n = 1), pulmonary embolism (n = 1), urinary tract infection (n = 1), and pneumothorax (n = 1). Long-term complications included deep venous thrombosis (n = 1) and intra-abdominal abscess (n = 1). Nineteen patients (33%) underwent robotic nephrectomy for RCC with level 1 (n = 1), level 2 (n = 17), and level 3 (n = 1) VTT. Average operative time was 283 minutes (range, 182-382 minutes), and average blood loss was 942 mL (range, 100-3000 mL). Average LoS was 3.11 days (range, 1-8 days). There were no deaths within 30 days. Short-term complications included pulmonary embolism (n = 1) and deep venous thrombosis (n = 1). Long-term complications included pleural effusion requiring thoracentesis (n = 1). All IVC reconstructions were performed by primary closure. Three (15.7%) cases required open conversion, two for control of the retrohepatic IVC and one for posterior lumbar venous bleeding unable to be controlled robotically. Postoperative imaging was completed in 12 (63.2%) of the patients undergoing a robotic procedure at a median of 340 days postoperatively. The vena cava was patent in all studies. The median percentage of postoperative to preoperative IVC diameter was 58% (axial) and 45% (sagittal). In comparing open vs robotic procedures, the robotic approach had a shorter LoS (P < .05), less intraoperative blood loss (P < .01), and similar operative times (P = NS). Robotic nephrectomy and IVC reconstruction for RCC with level 1 to level 3 VTT can be performed safely and effectively. The minimally invasive approach offers patients a shorter LoS, less intraoperative blood loss, and similar operative times compared with open surgery. Postoperative IVC diameter is maintained after robotic reconstruction. Proper selection of patients and robotic expertise are essential to optimize outcomes.

Laparoscopic donor right hepatectomy with reconstruction of segment V and VIII tributaries of the middle hepatic vein using a cadaveric iliac artery allograft

Laparoscopic donor right hepatectomy with reconstruction of segment V and VIII tributaries of the middle hepatic vein using a cadaveric iliac artery allograft

A Tailored Strategy for Recipient Hepatectomy: Left Portal Flow Preserving High Hilar Dissection

Summary: High hilar dissection (HHD) technique was reported as a novel technique for recipient hepatectomy. It allowed performing multiple tension-free duct to duct biliary anastomoses, hence reducing biliary complications. However, longer anhepatic phase is its main drawback. We describe a new modification of HHD technique, called left portal vein flow preserving HHD (LFP-HHD). It involves high intrahepatic division of hilar structures while maintaining the portal venous drainage through the left portal vein. Control of right hemi-liver inflow allows for division of the right hepatic vein, and further dissection of the retro-hepatic inferior vena cava easily and safely. Dissection of the anterior hilar structures can be accomplished. According to the co-ordination with the donor and bench surgery, the liver could be easily explanted. LFP-HHD technique is a novel simple technique for recipient hepatectomy that can be tailored for certain clinical conditions. It overcomes limitations of original HHD technique without compromising its merits.

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.

Hydrodissection of the Retrohepatic Space: A Technique to Physically Separate a Liver Tumour from the Inferior Vena Cava and the Ostia of the Hepatic Veins.

To report a technique of percutaneous retrohepatic hydrodissection, highlighting its potential to physically separate liver tumours from the inferior vena cava (IVC) and the ostia of the hepatic veins (HV). Between December 2017 and April 2018, hydrodissection of the retrohepatic IVC was performed in 5 patients (5 females; mean age 64.5years) undergoing percutaneous ablation of 5 liver metastases (mean size: 3.6cm) located adjacent to the IVC. Number of hydrodissection needles, volume of hydrodissection, separation of tumour/liver parenchyma from IVC/HV post-hydrodissection; technical success of ablation; and complications were tabulated. Two to three 22G spinal needles were required per case for adequate dissection. Mean volume to obtain sufficient hydrodissection was 410ml on average. Physical separation of the IVC and tumour/hepatic parenchyma was successful in all cases, by 9mm on average (range 5-12mm). It also leaded to physical separation of the ostia of the right and middle HV in all cases. There was no early or delayed complication, notably no venous thrombosis in the post-operative period. All lesions but one were completely ablated after one session at 3-month follow-up. The patient with residual tumour was successfully retreated. Retrohepatic hydrodissection is a feasible technique to separate a tumour from the IVC and/or ostia of the HV. This could potentially limit the heat-sink effect/reduce the risk of thrombosis. Larger follow-up studies are required to assess efficacy on a long-term basis.

Deploying the right Atrium for a failing Suprahepatic Vena Cava in living donor liver transplantation

A 50-year-old lady with polycystic liver disease underwent living donor liver transplantation due to recurrent cyst infection. Pre-operative CT scan showed gross hepatomegaly with severe compression of the inferior vena cava (IVC). Liver function was normal. During total hepatectomy, mobilization of the liver was difficult due to severe adhesion at the retrohepatic IVC. Bleeding from retrohepatic veins draining into IVC was encountered. The suprahepatic and infrahepatic vena cava was then clamped after division of the inflow vessels. As the right liver was rotated to expose the retrohepatic vein branches for ligation and division, the IVC was avulsed due to the shear force secondary to the heavy weight of the polycystic liver. A complete tear was noted 2 cm below the suprahepatic IVC clamp with a very thin tissue edge. IVC reconstruction with interpositional cadaveric vein graft was performed to restore the caval continuity. However, the cava was considered unsuitable for anastomosis with the right liver graft venoplasty due to poor tissue quality. As such, the right atrial appendage was approached via opening of the diaphragm. An interpositional polytetrafluoroethylene (PTFE) graft was first anastomosed to the liver graft venoplasty before orthotopic anastomosis between the atrial appendage and the suprarenal IVC (See Figure). The patient recovered well with good return of liver function. Postoperative CT Scan did not reveal any graft thrombosis at 4 months after the operation.

New Left Lobe Transplantation Procedure with Caval Reconstruction Using an Inverted Composite Graft for Chronic Budd-Chiari Syndrome in Living-Donor Liver Transplantation—A Case Report

When the Budd-Chiari syndrome (BCS) lesion extends to the inferior vena cava (IVC) or the orifices of the hepatic vein, the thickened IVC and/or hepatic vein wall must be removed and IVC reconstruction is required in living-donor liver transplantation (LDLT). In various reports about IVC resection in LDLT for BCS, there are none about left lobe liver transplantation with reconstruction of the retrohepatic IVC (rhIVC). To overcome removal and reconstruction of the rhIVC in LDLT for BCS, we introduced a composite IVC graft that is applicable to both right and left lobe partial liver grafts for LDLT for BCS. Pathogenic IVC was removed together with the native liver between the lower edge of the right atrium and 5 cm above the renal vein junction with the use of venovenous bypass. The e-polytetrafluoroethylene graft was anastomosed to the suprarenal intact IVC. Then the native part was detached at the level of just above the renal junction. The composite graft was inverted and a half rim of the native part of the graft was anastomosed to the posterior wall of the right atrium. Next, the common venous orifice of the left lobe graft was anastomosed to the wall defect which was composed of the anterior wall of the right atrium and the distal end of the native part of the composite graft. In conclusion, our inverted composite graft technique will overcome the weak points of LDLT for BCS, such as incomplete removal of the pathogenic caval wall and reconstruction of the rhIVC.

Clinical application of LDLT after reconstruction of IVC using artificial blood vessel in the treatment of HCC beyond Milan Criteria

Objective: To assess application of reconstruction of retrohepatic inferior vena cava using artificial blood vessel in right lobe living donor liver transplantation (LDLT) in the treatment of hepatocellular carcinoma (HCC) beyond Milan Criteria. Methods: The clinical data of 9 HCC patients who underwent right lobe liver transplantation after reconstruction of retrohepatic inferior vena cava using artificial blood vessel between June 2015 and Nov 2016 at Liver Transplantation Center of the First Affiliated Hospital of Nanjing Medical University were retrospectively analyzed. The liver of the patients was removed with retrohepatic inferior vena cava, and then the right donor graft was implanted by conventional orthotopic liver transplantation. Results: All 9 liver transplantations were performed successfully. The time of reconstruction of hepatic venous outflow of the donor graft was (22.6±3.0) min, anhepatic time was (45.0±7.1) min, and total operation time was (321.9±52.5) min. All patients recovered uneventfully, ICU and hospital stay day were (1.2±0.4) days and (18.4±3.0) days. 2 patients suffered from thrombosis of artificial blood vessel, one recovered after conservative treatment and another was treated by placement of vein stent. No abdominal/pulmonary infection and non-artificial blood vascular complications were found, and none died in perioperative period. Postoperative pathological results showed that all patients were hepatocellular carcinomas and vascular tumor thrombosis was found in 5 cases. All patients were follow up, 1 patient died of pulmonary and brain metastasis 10 months after operation. One patient survived with local recurrence of tumor in liver. The other patients had no tumor recurrence and metastasis. Conclusion: Replacement of retrohepatic inferior vena cava using artificial blood vessel in right lobe living donor liver transplantation is safe and feasible in the treatment of HCC beyond Milan Criteria, and might improve the resection rate of diseased liver and the prognosis of HCC patients after living donor liver transplantation.

Spectral analysis of heart rate variability predicts mortality and instability from vascular injury

BackgroundSpectral analysis of continuous blood pressure and heart rate variability provides a quantitative assessment of autonomic response to hemorrhage. This may reveal markers of mortality as well as endpoints of resuscitation. MethodsFourteen male Yorkshire pigs, ranging in weight from 33 to 36 kg, were included in the analysis. All pigs underwent laparotomy and then sustained a standardized retrohepatic inferior vena cava injury. Animals were then allowed to progress to class 3 hemorrhagic shock and where then treated with abdominal sponge packing followed by 6 h of crystalloid resuscitation. If the pigs survived the 6 h resuscitation, they were in the survival (S) group, otherwise they were placed in the nonsurvival (NS) group. Fast Fourier transformation calculations were used to convert the components of blood pressure and heart rate variability into corresponding frequency classifications. Autonomic tones are represented as the following: high frequency (HF) = parasympathetic tone, low frequency (LF) = sympathetic, and very low frequency (VLF) = renin-angiotensin aldosterone system. The relative sympathetic to parasympathetic tone was expressed as LF/HF ratio. ResultsBaseline hemodynamic parameters were equal for the S (n = 11) and NS groups. LF/HF was lower at baseline for the NS group but was higher after hemorrhage and the resuscitation period indicative of a predominately parasympathetic response during hemorrhagic shock before mortality. HF signal was lower in the NS group during the resuscitation indicating a relatively lower sympathetic tone during hemorrhagic shock, which may have contributed to mortality. Finally, the NS group had a lower VLF signal at baseline (e.g., [S] 16.3 ± 2.5 versus [NS] 4.6 ± 2.9 P < 0.05,) which was predictive of mortality and hemodynamic instability in response to a similar hemorrhagic injury. ConclusionsAn increased LF/HF ratio, indicative of parasympathetic predominance following injury and during resuscitation of hemorrhagic shock was a marker of impending death. Spectral analysis of heart rate variability can also identify autonomic lability following hemorrhagic injuries with implications for first responder triage. Furthermore, a decreased VLF signal at baseline indicates an additional marker of hemodynamic instability and marker of mortality following a hemorrhagic injury. These data indicate that continuous quantitative assessment of autonomic response can be a predictor of mortality and potentially guide resuscitation of patients in hemorrhagic shock.

Robot-assisted Retrohepatic Inferior Vena Cava Thrombectomy: First or Second Porta Hepatis as an Important Boundary Landmark

BackgroundRobot-assisted retrohepatic inferior vena cava (IVC) thrombectomy (RA-R-IVCTE) has been reported only for limited series. ObjectiveTo describe in detail the techniques for RA-R-IVCTE with regard to the relationship of a proximal thrombus to either the first porta hepatis (FPH) or second porta hepatis (SPH). Design, setting, and participantsFrom May 2013 to July 2016, 22 patients with R-IVC tumor thrombi were admitted to our hospital. Surgical procedureRA-R-IVCTE was performed using the Rummel tourniquet technique. For a proximal thrombus inferior to the FPH, we ligated some short hepatic veins (SHVs; typically 1–3). For a thrombus between the FPH and SPH, we mobilized the right lobe of the liver from the IVC by ligating additional SHVs. For a thrombus near or above the SPH but below the diaphragm, we mobilized both the right and left lobes of the liver to obtain high proximal control of the suprahepatic and infradiaphragmatic IVC, and simultaneously clamped the FPH. MeasurementsDetailed techniques were described for various scenarios and perioperative outcomes were recorded. Results and limitationsThe median operation time was 285min (interquartile range [IQR] 191–390). Intraoperative estimated blood loss was 1350ml (IQR 1000–2075ml). Some 63.6% of patients required an intraoperative blood transfusion and 68% were transferred to the intensive care unit after surgery. Grade IV complications developed in five cases. Vascular injuries (4 cases) were treated with intraoperative endoscopic sutures. An intestinal fistula was found on postoperative day 7 in one case; treatment with gastrointestinal decompression and drainage resolved the condition by 1 mo. ConclusionsEven though the risks involved are high, RA-R-IVCTE is feasible for selected patients. The FPH/SPH is an important boundary landmark for RA-R-IVCTE. The location of proximal IVC tumor thrombi in relation to the FPH or SPH should determine the technique used. Patient summaryRobot-assisted thrombectomy for retrohepatic inferior vena cava tumor thrombus is feasible in selected patients.

REBOA for the IVC? Resuscitative balloon occlusion of the inferior vena cava (REBOVC) to abate massive hemorrhage in retrohepatic vena cava injuries

The use of resuscitative endovascular balloon occlusion as a maneuver for occlusion of the aorta is well described. This technique has life-saving potential in other cases of traumatic hemorrhage. Retrohepatic inferior vena cava (IVC) injuries have a high rate of mortality, in part, due to the difficulty in achieving total vascular isolation. The purpose of this study was to investigate the ability of resuscitative balloon occlusion of the IVC to control suprahepatic IVC hemorrhage in a swine model of trauma. Thirteen swine were randomly assigned to control (seven animals) versus intervention (six animals). In both groups, an injury was created to the IVC. Hepatic inflow control was obtained via clamping of the hepatoduodenal ligament and infrahepatic IVC. In the intervention group, suprahepatic IVC control was obtained via a resuscitative balloon occlusion of the IVC placed through the femoral vein. In the control group, no suprahepatic IVC control was established. Vital signs, arterial blood gases, and lactate were monitored until death. Primary end points were blood loss and time to death. Lactate, pH, and vital signs were secondary end points. Groups were compared using the χ and the Student t test with significance at p < 0.05. Intervention group's time to death was significantly prolonged: 59.3 ± 1.6 versus 33.4 ± 12.0 minutes (p = 0.001); and total blood loss was significantly reduced: 333 ± 122 vs 1,701 ± 358 mL (p = 0.001). In the intervention group, five of the six swine (83.3%) were alive at 1 hour compared to zero of seven (0%) in the control group (p = 0.002). There was a trend toward worsening acidosis, hypothermia, elevated lactate, and hemodynamic instability in the control group. Resuscitative balloon occlusion of the IVC demonstrates superior hemorrhage control and prolonged time to death in a swine model of liver hemorrhage. This technique may be considered as an adjunct to total hepatic vascular isolation in severe liver hemorrhage and could provide additional time needed for definitive repair. Therapeutic study, level II.