Living-donor liver transplant for hepatocellular carcinoma located on hepatocaval confluence or in contact with the inferior vena cava is technically challenging, and candidates for this kind of procedure should be carefully selected. It is difficult to rule out major vascular invasion except after hepatectomy and histologic examination; in addition, the possible dissemination of cancer cells during recipient hepatectomy is a considerable risk. Herein, we report the first case in Saudi Arabia of right lobe living-donor liver transplant combined with inferior vena cava reconstruction using cryopreserved iliac vein graft after en bloc resection of the liver with part of the diaphragm, anterior wall of retrohepatic inferior vena cava, and a 5-cm hepatocellular carcinoma in segment 7. Our patient achieved so far 3-year disease-free survival. Tumor recurrence and risk of thrombosis related to inferior vena cava reconstruction are the main concerns; therefore, long-term follow-up of those patients is mandatory.
Key words : Inferior vena cava reconstruction, Liver tumors
Combined partial liver resections with partial or complete reconstruction of the retrohepatic inferior vena cava (IVC) have been previously described.1-4 Reports of living-donor liver transplant (LDLT) with total hepatectomy, including the retrohepatic vena cava and reconstruction of the IVC, have also been published.5-12 For patients with hepatocellular carcinoma (HCC) combined with cirrhosis, a liver transplant remains the best option for long-term survival. However, in the Model for End-Stage Liver Disease era, applying stringent criteria like Milan in light of the scarcity of organs exerts pressure on decision-making even before these patients are listed. In the setting of LDLT, there is no competition for organs, yet grafts from living donors are as precious and donor risk must be balanced against recipient survival.8
A 59-year-old female patient with hepatitis B virus cirrhosis and HCC underwent right lobe LDLT in March 2013. The HCC marginally exceeded Milan criteria, measuring 5.2 cm × 5.2 cm × 5 cm at segment 7 abutting retrohepatic IVC (Figure 1A). Under IVC cross-clamping, total hepatectomy was performed en bloc with a part of the diaphragm and an anterior wall of the retrohepatic IVC without mobilizing the liver off the IVC to minimize the risk of tumor dissemination (7 cm in length and around 50% of IVC circumference). Reconstruction of IVC was performed utilizing a cryopreserved deceased-donor iliac vein graft (Figure 2). This is the first report to describe this approach in Saudi Arabia.
The right lobe graft was retrieved without the middle hepatic vein; segment V and VIII veins were not sizable and hence did not necessitate reconstruction. Graft weight was 651 g, and graft-to-recipient weight ratio was 1.2.
For total hepatectomy and partial resection of IVC, complete caval cross-clamping was mandatory. For this, a deceased-donor cryopreserved iliac vein graft patch was fashioned for IVC reconstruction. The patient tolerated the IVC clamping time (23 min) well. Subsequently, the IVC was unclamped and blood flow was reinstituted and checked for bleeding and patency. The IVC was partially occluded, and a longitudinal 30-mm-slit venotomy was performed in the right upper paramedian aspect of the cava to accommodate the right hepatic vein anastomosis using 4-0 polydioxanone sutures. The portal venous anastomosis was completed using 5-0 polydioxanone sutures. Portal perfusion was uneventful, with warm ischemic time of 44 minutes; cold ischemic time was 66 minutes. Hepatic artery reconstruction was performed in standard fashion using interrupted 8-0 prolene sutures, and duct-to-duct biliary anastomoses was performed using interrupted 7-0 polydioxanone sutures. The patient received a postoperative prophylactic dose of subcutaneous heparin during hospital admission. No long-term anticoagulation was given. The donor was discharged 1 week after operation and remained without problems during follow-up.
Histopathologic analysis of explanted liver showed a well-differentiated HCC (4 cm in diameter) surrounded by a thick capsule that was adherent to but not infiltrating the IVC; sections from the right hepatic vein did not show any evidence of venous infiltration (Figure 3). Sections from hilar vessels, lymph nodes, and the resected portion of the diaphragm showed no tumor involvement. No other lesions were identified.
The patient’s postoperative course was uneventful. There was no renal dysfunction. The patient was discharged in good general condition for follow-up in an outpatient clinic. Magnetic resonance imaging was done 9 months postoperatively on suspicion of biliary stricture due to hyperbilirubinemia and unstable enzyme levels. Anastomotic biliary stricture was confirmed and managed by a single session of percutaneous dilatation and stenting. The plastic stent was removed 3 months later, with the patient remaining asymptomatic since removal. Follow-up magnetic resonance imaging in March 2015 showed no recurrence of HCC and no biliary dilatation. The patient has remained well with good graft function. Levels of alpha-fetoprotein have never been elevated.
Living-donor liver transplant for HCC located on the hepatocaval confluence or in contact with the IVC is technically challenging, and candidates for this kind of procedure should be carefully selected. In LDLT, the native IVC is preserved for a piggyback technique during engraftment, which carries the risk of dissemination of cancer cells during recipient hepatectomy or the possibility of tumor remnants. It is difficult to rule out major vascular invasion except after hepatectomy and histologic examination. Autologous, allogenic, and even artificial synthetic grafts have been used for vessel reconstruction in liver transplant procedures with encouraging results.6,7,9,10 In reports of LDLT with total hepatectomy including the retrohepatic vena cava with reconstruction of the IVC for malignancy have also been published,5-12 some tumors even exceeded Milan criteria.6
In summary, we report the first case of caval replacement in LDLT in Saudi Arabia, showing 3-year survival at follow-up and at least 2 years of disease-free survival (Figure 1B). This case, along with other reports, shows the potential benefit of liver transplant in selected patients with HCC. However, risk of thrombosis related to IVC reconstruction and cancer recurrence are the main concerns; therefore, long-term follow-up of these patients is necessary.
Volume : 16
Issue : 5
Pages : 625 - 627
DOI : 10.6002/ect.2016.0100
From the Departments of Liver and Small Bowel Transplantation and
Hepatobiliary and Pancreatic Surgery, King Faisal Specialist Hospital and
Research Hospital, Riyadh, Saudi Arabia
Acknowledgements: The authors declare that they have no sources of funding for this study, and they have no conflicts of interest to declare.
Corresponding author: Firas Zahr Eldeen, Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital & Research Centre, MBC 72, PO Box 3354, Riyadh 11211, Saudi Arabia
Phone: +966 11 557 6163
Figure 1. Preoperative Images of a 5-cm Hepatocellular Carcinoma Tumor Abutting the Inferior Vena Cava (a) and 2 Years Posttransplant (B)
Figure 2. Inferior Vena Cava Reconstruction Using Cryopreserved Iliac Vein Graft
Figure 3. Liver with Hepatocellular Carcinoma Cut on Back-table