title: Hepatocellular carcinoma on cirrhosis complicated with tumoral thrombi extended to the right atrium: results in three cases treated with major hepatectomy and thrombectomy under hypothermic cardiocirculatory arrest and literature review.
abstract: BACKGROUND
  Hepatocellular carcinoma (HCC) with the presence of tumor thrombus in hepatic veins and vena cava, until the atrium (RATT), is correlated with poor prognosis and with risk of tricuspid valve occlusion, congestive heart failure, and pulmonary embolism.
  
  
  METHODS
  Three patients with HCC on cirrhotic liver with RATT were studied. Operative technique, pre-operative and post-operative liver function tests, blood loss and transfusions, post-operative morbidity and mortality, and the overall survival and the disease free survival were analyzed.
  
  
  RESULTS
  Mean operative time was 336 ± 66 min. Intra-operative blood loss was 926.6 ± 325.9 ml. No major complications occurred. The times of hospital stay were 10, 21, and 19 days, respectively. The survival times were 90, 161, and 40 days, and the disease-free survival times were 30, 141, and 30 days, respectively.
  
  
  CONCLUSIONS
  The complete removal of HCC with RATT may be achieved with cardiopulmonary by-pass (CPB) and total hepatic vascular exclusion (THVE). Adding the hypothermic cardiocirculatory arrest (HCCA) to the use of CPB allowed us to have minimal blood loss and hemostasis of the resectional plane. So the use of CPB and HCCA should be considered a good therapeutic alternative to the normothermic CPB with THVE.
authors.affiliation: Unit of Surgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy.
authors.forename: Benedetta
authors.initials: B
authors.lastname: Pesi
authors.affiliation: Unit of Surgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Giudici
authors.affiliation: Unit of Surgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Moraldi
authors.affiliation: Department of heart and vessels, Careggi University Hospital, Florence, Italy.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Montesi
authors.affiliation: Department of anesthesia and critical care-Department of healt science, Careggi University Hospital, Florence, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Romagnoli
authors.affiliation: Department of anesthesia and critical care-Department of healt science, Careggi University Hospital, Florence, Italy.
authors.forename: Fulvio
authors.initials: F
authors.lastname: Pinelli
authors.affiliation: Department of heart and vessels, Careggi University Hospital, Florence, Italy.
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Stefano
authors.affiliation: Unit of Surgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Florence, Italy. g.batignani@unifi.it.|Unit of Surgery, Department of Surgery and Translational Medicine, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy. g.batignani@unifi.it.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Batignani
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000209:etiology / Q000473:pathology / Q000628:therapy*; D050792:Circulatory Arrest, Deep Hypothermia Induced; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000473:pathology*; D006498:Hepatectomy; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008113:Liver Neoplasms / Q000209:etiology / Q000473:pathology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D017131:Thrombectomy; D013927:Thrombosis / Q000150:complications*
keywords: Hepatocellular carcinoma; Hypothermic cardiocirculatory arrest; Right atrium; Thrombectomy