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156 C. Lim et al.
Fig. 11.9 Venovenous bypass. a, b Dissection and cannulation of the inferior mesenteric vein.
c Percutaneous cannulation of the right femoral vein. d Percutaneous cannulation of the left
axillary vein. e, f Extracorporeal circulation
thermistor probe thermometer into the future liver remnant. Topical cooling of the
liver remnant was also applied.
In our patient, an anterior approach technique was performed because of the
potential adherence between the posterior mass and the replaced IVC. Then, the
right liver was fully mobilized to expose the root of the right hepatic vein, which
was ligated and divided. When the liver transection was completed, the liver was
flushed with serum albumin (500 mL) via the portal vein. The cannula of portal
perfusion and the caval drainage were then removed. The portal vein hole was
rinsed with heparin and sutured transversally with interrupted vascular sutures to
prevent stenosis. Circulation was then restored as for standard TVE. The portal
cannula of the bypass was clamped quickly upon revascularization of the remaining
left liver to optimize portal reperfusion. The bypass was stopped and removed when
hemodynamic stability was confirmed by the anesthesiologists. Doppler ultrasonography was used to assess the patency of vessels. The Doppler imaging also
helped optimize the position of the remaining liver by preventing any vascular
kinking of the hepatic veins or the suprahepatic vena cava. The venovenous bypass
lasted 120 min and TVE 55 min. Blood loss was 1000 ml. The patient received two
units of packed red blood cells.
11 Resection of Renal Cell Carcinoma Involving the Liver … 157
Fig. 11.10 a Right subcostal incision combined to midline incision. b, c The portal vein was
catheterized above the portal triad clamp. d Clamping of the portal triad. e Infrahepatic inferior
vena cava clamping (below the prosthetic graft). f Intrapericardial vena cava clamping
Fig. 11.11 The clamp was
located below the prosthetic
graft
158 C. Lim et al.
Discussion
The main technical aspect which is the in situ hypothermic technique with the use
of venovenous bypass of this procedure could be discussed. With the advance in
surgical technique, liver resection under hypothermic perfusion remains rare (3% in
our experience). It is mainly indicated for tumors invading the cavo-hepatic junction and if complex vascular reconstruction is required for the remnant liver. The
majority of patients with “limited vascular invasion or contact” can nowadays be
operated on safely with intermittent occlusion of the hepatic pedicle. Another
possibility could be to start the hepatic transection under intermittent clamping of
the hepatic pedicle and apply short TVE when approaching the vascular contact
with the replaced IVC. In this case, isolated occlusion of the replaced IVC should
be avoided to limit postoperative IVC thrombosis.
Alternatives Approaches
• The decision to proceed for IVC reconstruction should depend upon
preoperative criteria (lower extremity edema, collateral venous pathways
on the radiological imaging).
• The IVC reconstruction is not without postoperative risks, including
thrombosis and sepsis.
• In case of IVC resection combined with right nephrectomy, left renal vein
reconstruction is not mandatory. But in case of IVC resection with left
nephrectomy, right renal vein reconstruction is mandatory.
Short-Term Outcome
The postoperative course was uneventful. The patient did not experience postoperative liver failure or acute kidney injury. The liver tests were normal at discharge.
Postoperative MDCT was normal and show patency of the replaced IVC
(Fig. 11.12).
In our reported experience, this complex procedure performed for primary and
secondary liver tumors achieved a five-year survival rate of 30.4% and a high
90-day mortality of 19.5% [13]. Risk factors for postoperative mortality include
Charlson comorbidity index 3 (indicating at least 2 comorbid conditions),
maximum tumor diameter 10 cm, and the presence of 50/50 criteria on postoperative day 5 were independent predictors of surgical mortality measured at
90 days.
11 Resection of Renal Cell Carcinoma Involving the Liver … 159
Fig. 11.12 Postoperative
computed tomography after
right hepatectomy
160 C. Lim et al.
Long-Term Outcome
RCC can metastasize to almost every organ. Metastatic RCC represent 30% of RCC
at diagnosis and occur in 15–30% following nephrectomy [25–27]. The most
common metastatic sites include lung (50–60%), bone (30–40%), liver (30–40%),
and brain (5%). Unusual sites of metastases include thyroid, pancreas, muscle, and
skin [28]. To date, the European Association of Urology recommended in their
guidelines that surgical resection of metastases from RCC should be considered for
most metastatic sites, with the exception of brain and bones. To date, surgical
resection remains the only curative treatment of metastases from RCC with a
five-year survival rate of 30–45% for patients who underwent surgical resection of
metastases whatever the sites [29–32]. Surgery for the metastases from RCC can be
proposed if it concerns an isolated metastatic site and if complete resection can be
achieved regardless of the length of the disease-free interval (synchronous vs.
metachronous) [33]. Of course, a longer disease-free interval foll owing nephrectomy has been shown to be a positive prognostic factor [34].
Survival data reported from targeted therapy clinical trials showed a median
overall survival between 26.4 and 32 months for patients who received sunitinib or
combined sunitinib and everolimus [35, 36].
Liver metastases from RCC, like any other metastatic lesions, can be treated by
surgery, systemic chemotherapy, radiotherapy, percutaneous ablation, and transarterial chemoembolization. Su rgical resection of liver metastases from RCC
achieved survival rates of 26–54% at 3 years with a median survival time reaching
48 months. The three-year survival rates for patients treated by chemotherapy and
interferon were 15 and 48%, respec tively [28]. Although TACE can result in a
favorable local tumor response, survival rates are less favorable than those achieved
by surgery with one- and two-year survival rates (from the start of treatment) for
patients treated with TACE of 31 and 6%, respectively, with a median survival time
of 8.8 months [37].
In our case, the patient recurred in the liver 15 months later following right
nephrectomy and IVC thrombectomy for a RCC with tumor thrombus extending
into the retrohepatic IVC.
Global Pearls
• The anatomic level of the tumor thrombus within the inferior vena cava
according to the classification by Neves and Zincke dictates the surgical
strategy.
• Surgery of the IVC requiring infrahepatic and retrohepatic inferior vena
cava (below the level of the hepatic veins) control are usually well tolerated in terms of hemodynamics, especially when the inferior vena cava
is completely obstructed by the thrombus. While surgery of the IVC
combined with standard total vascular exclusion of the liver can induce
hemodynamic consequences with a risk of postoperative liver failure.
11 Resection of Renal Cell Carcinoma Involving the Liver … 161
• Use of venovenous bypass and hypothermic perfusion of the liver can
decrease the risk of postoperative liver failure, particularly when a vascular reconstruction is needed or standard vascular exclusion of the liver is
planned to last >60 min.
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Part II
Gallbladder/Bile Duct
Hilar Cholangiocarcinoma with Portal Vein Involvement
Ryan T. Groeschl and David M. Nagorney
Case Presentation
A 64-year-old man with several years of diarrhea and crampy abdominal pain
underwent CT enterography. Assessment of the liver demonstrated severe atrophy
of the left lobe, with the absence of a visible left portal vein (Fig. 12.1). He was not
jaundiced. Serum bilirubin was normal and CA 19-9 was 76 U/mL. His past
medical and surgical history was non-contributory.
A contrast-enhanced MRI with MRCP was obtained to further characterize the
liver and bile ducts, particularly at the hepatic hilus. MRI reveal ed a distinct 2.7 cm
mass in the left lobe that caused a tight stenosis of the main left hepatic duct without
visualization of the left portal vein (Fig. 12.2). There was also irregular contour of
the common hepatic duct on MRCP. The clinical diagnosis was type IIIb HC. There
was no evidence of distant disease on either CT or MRI. No effort was made to
obtain a tissue diagnosis preoperatively.
The complete absence of a visible left portal vein supported the preoperative
assumption of malignant obstruction of the left portal vein. The presence of lobar
hepatic atrophy and the absence of jaundice and cholangitis obviated the need for
any preoperative intervention. An en-bloc left hepatectomy, extrahepatic bile duct
resection, regional lymphadenectomy, and Roux-en-Y hepaticojejunostomy were
performed. Intraoperatively, the malignant involvement of the left portal vein
12
R.T. Groeschl (&) D.M. Nagorney
Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester,
MN 55905, USA
e-mail: groeschl.ryan@mayo.edu
D.M. Nagorney
e-mail: nagorney.david@mayo.edu
© Springer International Publishing AG 2017
T.M. Pawlik et al. (eds.), Case-Based Lessons in the Management of Complex
Hepato-Pancreato-Biliary Surgery, DOI 10.1007/978-3-319-50868-9_12
167