title: Complex Liver Resection Using Standard Total Vascular Exclusion, Venovenous Bypass, and In Situ Hypothermic Portal Perfusion: An Audit of 77 Consecutive Cases.
abstract: OBJECTIVE
  To identify independent predictors of 90-day mortality after liver resection for patients undergoing standard total vascular exclusion (TVE) with hypothermic portal perfusion and venovenous bypass. The secondary endpoint was to evaluate the long-term outcomes.
  
  
  BACKGROUND
  Tumors invading the vena cava and/or the hepatocaval confluence are indications for standard TVE. The inclusion of liver hypothermic perfusion permits safe TVE. There are a limited number of reports focusing on this complex technique and no relevant analysis of short-term and long-term results.
  
  
  METHODS
  Seventy-seven consecutive liver resections performed using standard TVE with hypothermic portal perfusion and venovenous bypass between 1998 and 2010 were analyzed. The independent predictors and rates of 90-day mortality, morbidity, and long-term survival were evaluated.
  
  
  RESULTS
  The 90-day mortality rate was 19.5% (15 cases). Three independent predictors of mortality were identified: age-adjusted Charlson Comorbidity Index 3 or more (P = 0.0231; odds ratio = 47.565; 95% confidence interval = 1.701-1330.414), tumor size 10 cm or more (P = 0.0442; odds ratio = 6.374; 95% confidence interval = 1.049-38.734), and the presence of 50/50 criteria (P = 0.0407; odds ratio = 6.217; 95% confidence interval = 1.080-35.782). The overall 5-year survival rate was 30.4%.
  
  
  CONCLUSIONS
  Liver resection using standard TVE with hypothermic portal perfusion and venovenous bypass is associated with a high mortality rate. The identification of preoperative predictors of mortality should improve the selection of patients for this aggressive surgery. Compared with nonsurgical management, the long-term results are acceptable and justify this aggressive surgery in selected patients.
authors.affiliation: *AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France †AP-HP Hôpital Henri Mondor, Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique. Créteil, France ‡Inserm, Unité 955, Créteil, France; and §Inserm, Unité 785, Villejuif, France.
authors.forename: Daniel
authors.initials: D
authors.lastname: Azoulay
authors.forename: Chetana
authors.initials: C
authors.lastname: Lim
authors.forename: Chady
authors.initials: C
authors.lastname: Salloum
authors.forename: Paola
authors.initials: P
authors.lastname: Andreani
authors.forename: Umberto
authors.initials: U
authors.lastname: Maggi
authors.forename: Tonine
authors.initials: T
authors.lastname: Bartelmaos
authors.forename: Denis
authors.initials: D
authors.lastname: Castaing
authors.forename: Gérard
authors.initials: G
authors.lastname: Pascal
authors.forename: Feetal
authors.initials: F
authors.lastname: Fesuy
mesh_terms: D000328:Adult; D000368:Aged; D003135:Common Bile Duct / Q000601:surgery; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006499:Hepatic Artery / Q000601:surgery; D006503:Hepatic Veins / Q000473:pathology / Q000601:surgery; D006801:Humans; D007036:Hypothermia, Induced; D008099:Liver / Q000098:blood supply / Q000473:pathology / Q000601:surgery; D008107:Liver Diseases / Q000209:etiology; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D018579:Patient Selection; D011169:Portal Vein / Q000601:surgery; D015427:Reperfusion Injury / Q000209:etiology; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome; D019043:Vascular Neoplasms / Q000556:secondary / Q000601:surgery*; D014682:Vena Cava, Inferior / Q000473:pathology / Q000601:surgery