Korean J Transplant.  2021 Jun;35(2):130-136. 10.4285/kjt.20.0056.

Recipient hepatectomy under total hepatic vascular exclusion to prevent hepatocellular carcinoma spread in living donor liver transplantation

• Yoon YI
• Hwang S
• Moon DB
• Jung DH
• Lee SG

• KMID: 2517297
• DOI: http://doi.org/10.4285/kjt.20.0056

Abstract

We present a case of recipient hepatectomy under total hepatic vascular exclusion (THVE) and venovenous bypass for living donor liver transplantation (LDLT) in a patient with multiple hepatocellular carcinomas (HCCs) closely located to the retrohepatic inferior vena cava (IVC). A 19-year-old male patient diagnosed with multiple HCCs underwent left lateral sectionectomy 14 months before and received four sessions of transarterial chemoembolization due to post-hepatectomy tumor recurrence. These pretransplant sequences implicated high risk of posttransplant HCC recurrence. However, LDLT was performed with expectation of prolonged survival. During recipient operation, the portal vein was transected and active venovenous bypass was performed. Supra- and infra-hepatic portions of the retrohepatic IVC were then clamped. Under THVE and portal vein bypass, recipient hepatectomy was meticulously performed. A modified right liver graft recovered from his brother was implanted according to standard procedures of LDLT. The patient recovered uneventfully from LDLT operation. However, multiple pulmonary metastasis occurred. The patient has been doing well for 12 months after LDLT, with administration of chemotherapeutic agents. Although early pulmonary metastasis occurred in this patient, we suggest that recipient hepatectomy under THVE and venovenous bypass can be a feasible technical option to cope with risk of iatrogenic tumor cell spread during LDLT operation.

Keyword

Hepatectomy; Tumor recurrence; Tumor cell spread; Inferior vena cava; Pulmonary metastasis

Figure

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  Fig. 1 (A-D) Pretransplant dynamic computed tomography showing lipiodol uptake of multiple viable hepatocellular carcinomas.

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  Fig. 2 Intraoperative photographs of recipient hepatectomy. (A) The hepatoduodenal ligament is meticulously dissected, and then the right hepatic artery and the bile duct are transected. (B) The supra- and infra-hepatic portions of the retrohepatic inferior vena cava (IVC) are encircled with vascular tourniquets. (C) The right portal vein is transected and portal flow is diverted through the active venovenous bypass connected to the internal jugular vein pathway. (D) Under total hepatic vascular exclusion and portal vein bypass, the caudate lobe is meticulously dissected from the retrohepatic IVC and the right liver is fully mobilized.

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  Fig. 3 Photographs of the explant liver showing multiple tumors with partial necrosis.

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  Fig. 4 Posttransplant liver dynamic computed tomography findings. The unusual findings of modified right liver graft implantation are visible at the image taken at 2 weeks (A) and 6 months (B) after the transplantation.

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  Fig. 5 Posttransplant chest dynamic computed tomography findings. (A) Multiple small nodules (arrow) are identified in the image taken at 4 months after the transplantation. (B) The number and size of lung nodules are increased (arrow) in the image taken at 9 months after the transplantation.

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