title: Liver resection using total vascular exclusion of the liver preserving the caval flow, in situ hypothermic portal perfusion and temporary porta-caval shunt: a new technique for central tumors.
abstract: Standard total vascular exclusion (TVE) of the liver is indicated for resection of tumors involving or adjacent to the vena cava and/or the confluence of the hepatic veins. The duration of liver ischemia can be prolonged by combined portal hypothermic perfusion of the liver (in or ex situ). The use of a venovenous bypass (VVB) during standard TVE maintains stable hemodynamics as well as optimal renal and splanchnic venous drainage. When the hepatic veins can be controlled, TVE preserving the caval flow negates the need for VVB. However this technique remains limited in duration as it is performed under warm ischemia (so-called normothermia) of the liver. To prolong the ischemia time, we have designed a modification of TVE with preservation of the caval flow including the use of temporary porta-caval shunt (PCS) and hypothermic perfusion of the liver. We describe here the first two cases of this new technique. Two patients underwent left hepatectomy extended to segments 5 and 8 (also called extended left hepatectomy) for large centrally located tumors. TVE lasted seventy-two and seventy-nine minutes, respectively. The postoperative course was uneventful and both patients were discharged on day ten and day twenty-five respectively. Both are alive without recurrence at ten and seven months following surgery. Provided the roots of the hepatic veins can be controlled, this technique combines the advantages of standard TVE with in situ hypothermic perfusion and VVB and obviates the need and the subsequent risks of the latter.
authors.affiliation: Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France.
authors.forename: Daniel
authors.initials: D
authors.lastname: Azoulay
authors.affiliation: Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France.
authors.forename: Umberto
authors.initials: U
authors.lastname: Maggi
authors.affiliation: Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France.
authors.forename: Chetana
authors.initials: C
authors.lastname: Lim
authors.affiliation: Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Malek
authors.affiliation: Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Compagnon
authors.affiliation: Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France.
authors.forename: Chady
authors.initials: C
authors.lastname: Salloum
authors.affiliation: Department of Hepato-Biliary Surgery and Liver Transplantation, AP-HP, U.F.R. de médecine de l'Université Paris XII-Créteil, France.
authors.forename: Alexis
authors.initials: A
authors.lastname: Laurent
keywords: Total vascular exclusion (TVE); hypothermic perfusion; porta-caval shunt (PCS); venovenous bypass (VVB)