Weiner Joshua, Hemming Alan, Levi David, Beduschi Thiago, Matsumoto Rei, Mathur Abhishek, Liou Peter, Griesemer Adam, Samstein Benjamin, Cherqui Daniel, Emond Jean, Kato Tomoaki
Department of Surgery, Columbia University, New York City, NY.
Department of Surgery, University of Iowa, Iowa City, IA.
Ann Surg. 2022 Nov 1;276(5):854-859. doi: 10.1097/SLA.0000000000005640. Epub 2022 Aug 2.
We herein advocate for more extensive utilization of ex vivo resection techniques for otherwise unresectable liver tumors by presenting the largest collective American experience.
Advanced in situ resection and vascular reconstruction techniques have made R0 resection possible for otherwise unresectable liver tumors. Ex vivo liver resection may further expand the limits of resectability but remains underutilized due to concerns about technical complexity and vascular thrombosis. However, we believe that the skillset required for ex vivo liver resection is more widespread and the complications less severe than widely assumed, making ex vivo resection a more attractive option in selected case.
We retrospectively analyzed 35 cases performed by surgical teams experienced with ex vivo liver resections (at least 4 cases) between 1997 and 2021.
We categorized malignancies as highly aggressive (n=18), moderately aggressive (n=14), and low grade (n=3). All patients underwent total hepatectomy, vascular reconstruction and resection in hypothermia on the backtable, and partial liver autotransplantation. Overall survival was 67%/39%/28%, at 1/3/5 years, respectively, with a median survival of 710 days (range: 22-4824). Patient survival for highly aggressive, moderately aggressive, and low-grade tumors was 61%/33%/23%, 67%/40%/22%, and 100%/100%/100% at 1/3/5 years, respectively, with median survival 577 days (range: 22-3873), 444 days (range: 22-4824), and 1825 days (range: 868-3549).
Ex vivo resection utilizes techniques commonly practiced in partial liver transplantation, and we demonstrate relatively favorable outcomes in our large collective experience. Therefore, we propose that more liberal use of this technique may benefit selected patients in centers experienced with partial liver transplantation.
通过展示美国最大规模的综合经验，我们在此提倡更广泛地利用体外切除技术来治疗原本无法切除的肝肿瘤。
先进的原位切除和血管重建技术已使原本无法切除的肝肿瘤实现R0切除成为可能。体外肝切除可能会进一步扩大可切除范围，但由于担心技术复杂性和血管血栓形成，其应用仍未得到充分利用。然而，我们认为，体外肝切除所需的技能更为普及，并发症也比普遍认为的要轻，这使得体外切除在某些病例中成为更具吸引力的选择。
我们回顾性分析了1997年至2021年间由有体外肝切除经验（至少4例）的手术团队进行的35例手术。
我们将恶性肿瘤分为高侵袭性（n = 18）、中度侵袭性（n = 14）和低级别（n = 3）。所有患者均接受了全肝切除、血管重建以及在体外低温条件下的切除，并进行了部分肝脏自体移植。1年、3年、5年的总生存率分别为67%/39%/28%，中位生存期为710天（范围：22 - 4824天）。高侵袭性、中度侵袭性和低级别肿瘤患者的1年、3年、5年生存率分别为61%/33%/23%、67%/40%/22%和100%/100%/100%，中位生存期分别为577天（范围：22 - 3873天）、444天（范围：22 - 4824天）和1825天（范围：868 - 3549天）。
体外切除采用了部分肝移植中常用的技术，并且在我们大规模的综合经验中显示出相对良好的结果。因此，我们建议在有部分肝移植经验的中心更广泛地使用该技术可能会使部分患者受益。
