Extended Left Hepatectomy with Inferior Vena Cava Replacement and Right Hepatic Vein Re-implantation Under In Situ Cooling and Venous Bypass for Advanced Intrahepatic Cholangiocarcinoma: H123458-RHV-IVC.

Abstract

Background: Resection of intrahepatic cholangiocarcinoma (iCCA) with invasion of major venous structures is controversial because of its significant morbidity and mortality and questionable oncological value.^1,2 We report on a case of long-term survival after extreme liver surgery in a patient with advanced iCCA.³ METHODS: A 51-year-old woman was referred for locally advanced, biopsy-proven iCCA. Imaging showed an 8 cm mass involving the inferior vena cava (IVC) and hepatic veins confluence with no evidence of extrahepatic disease. The procedure included an extended left hepatectomy with IVC and right hepatic vein (RHV) resection and reconstruction. The measured future liver remnant was 884 mL.

Results: The procedure began with liver mobilization, hilar dissection, and lymphadectomy. Total vascular exclusion (TVE) was required and an elective venous bypass was created using the femoral and inferior mesenteric veins to the axillary vein. TVE was placed, and liver cooling was performed using 3 L of IGL solution delivered through the left portal vein stump, vented by an opening in the IVC. An extended left hepatectomy with en bloc resection of the retrohepatic IVC and main hepatic veins was performed. At the end of the transection, tumor contact was confirmed at the distal end of the RHV, resulting in an R1 vascular resection. A posterior patch of the RHV, including three constitutive branches, was kept for reconstruction. The IVC was replaced with a 16 Fr polytetrafluoroethylene (PTFE) graft, and an RHV patch was re-implanted on the side of the PTFE graft. The duration of both the surgery and the venous bypass was 560 and 130 min, respectively. The patient developed transient postoperative hepatic failure and was discharged on day 18. The pathology results indicated pT3N0 stage with a focal R1 margin, as seen during surgery. The patient declined adjuvant treatment. Eight years after surgery, the patient is alive and disease-free, with excellent quality of life.

Conclusions: Extreme surgical approaches can allow for long-term survival and possible cure in selected patients with advanced iCCA. Focal R1 resection may occur in such instances and should be considered on a case-by-case decision.