EXTREME LIVER SURGERY: the forgotten surgery for hepatocaval tumors

Surgery,hepatic, Complications,haemorrhage
J. Lopez Fernandez1, B. Hernando1, S. Torres1, B. Pardina1, C. Hernandez1, C. Codony2

1Department of Anesthesiology of Hospital Universitari Doctor Josep Trueta - Girona (Spain), 2Department of General Surgery of Hospital Universitari Doctor Josep Trueta - Girona (Spain)

Background and Goal of Study:Hepatic tumors that involves the hepatocaval confluence are classically considered irresolvable. However, extreme liver surgery can be used by curative intention. This technique includes total vascular liver exclusion, femoro-porto-jugular venovenous bypass and liver parenchyma cooling, with consequent reperfusion syndrome and the high risk of liver failure.

It is an infrequent surgery. The aim of this study is analyze the survival and recognize intra and postoperative complications.

Materials and Methods: Is a retrospective descriptive case series, includes 13 patients operated by extreme liver surgery from April 2008 to March 2017 in Hospital Universitari Doctor Josep Trueta Girona.

Patients included were 7 women and 6 men, aged 58±10 years old  and ASA III. General anesthesia was performed in all cases (desfluorane, remifentanil continuous perfusion and rocuronium). Patients were administered tranexamic acid (loading and maintenance doses, 10mg/kg and 1mg/kg/h), calcium infusion rate of 100mg/h and 1 liter of 5% albumin, patients were accessed with rapid infusion vascular catheter, central venous catheter and high caliber peripheral access. Basic monitoritzation, invasive blood presure, invasive hemodinamic monitoritzation, TOF and BIS. The last surgery we used cerebral oximetry and tromboelastogram. The posoperatory admision was in our ICU for a deferred awaken.

Results and Discussion:The mean bypass duration 124±23 minutes, cold ischemia interval 88±15 minutes and normothermal ischemia interval 20±8 minutes. 

In this series were no intraoperative deads. However, 4 died in the postoperative, 2 in the first week due to liver failure. Therefore, 30-day survival was 76%, 90-day survival was 69% and 3-year survival was 50%. 5 intraoperative incidences were registered: 3 cases of massive bleeding requiring politransfusion, 1 technical surgery difficulty and 1 portal thrombosis. In postoperative period were registered 7 cases of bleeding (2 required relaparotomy) and 4 several liver insufficiency that died, 4 moderate or mild liver insufficiency.

Conclusion:Extreme liver surgery is high risk surgery with intra or posoperative complications and high morbi-mortality, especially the masseive bleeding that requeries politransfusion. Otherwise, 3-year survival was 50% and 2-year survival was 75%.

This is a small case series, so cannot draw high evidence conclusions. Extreme liver surgery is a terapeutic option to consider.

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