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Chirurgie hépatique sous perfusion hypothermique - D. Azoulay

Journées chirurgie 2022

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1. Rational for hypothermic perfusion
2. Clarification: In situ - Ex situ
3. Veno-Venous Bypass: yes-no?, never-always?
4. Our experience and lessons learned
Hepatectomy & Hypothermic Perfusion of the Liver
Daniel Azoulay
1. Rational for hypothermic perfusion
1. Rational for hypothermic perfusion
Chirurgie hépatique sous perfusion hypothermique - D. Azoulay
The « central column » of the liver
and the frequent need for total & prolonged
vascular exclusion of the liver
1. Rational for hypothermic perfusion
Azoulay D, et al., HPB in Press
Belghiti J, et al., Ann Surg 1996
1. Rational for hypothermic perfusion
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Chirurgie hépatique sous perfusion hypothermique - D. Azoulay

  • 1. 1. Rational for hypothermic perfusion 2. Clarification: In situ - Ex situ 3. Veno-Venous Bypass: yes-no?, never-always? 4. Our experience and lessons learned Hepatectomy & Hypothermic Perfusion of the Liver Daniel Azoulay
  • 2. 1. Rational for hypothermic perfusion
  • 3. 1. Rational for hypothermic perfusion
  • 5. The « central column » of the liver and the frequent need for total & prolonged vascular exclusion of the liver 1. Rational for hypothermic perfusion Azoulay D, et al., HPB in Press
  • 6. Belghiti J, et al., Ann Surg 1996 1. Rational for hypothermic perfusion
  • 7. Total Vascular Exclusion - Hemodynamical Intolerance 10-20% - Splanchnic congestion - Continuous and subsequently Time Limited -« Consensual » Limit = 60 minutes Limits of Standard TVE 1. Rational for hypothermic perfusion
  • 8. Vascular Exclusion with Venous Bypass Solves the problems of - hemodynamical intolerance - splanchnic congestion But continuous = remains time limited Limits of Standard TVE
  • 9. Metabolic needs: 2.0-fold decrease for every 10°C decline in tissue temperature. Techniques & Technologies of LT. Kato, et al., Am J Physiol Gastrointest Liver Physiol 2002 + LR under hypothermic perfusion of the liver. =
  • 10. In Situ : Portal triade untouched … no need for reconstruction Ex Situ : Portal triade divised and… needs reconstruction Clarification In situ - Ex situ : variations on a theme HYPOTHERMIC PERFUSION Always in Vivo…
  • 11. Delriviere, Hannoun, J Am Coll Surg. 1995 In Situ - Ante situm Resection Clarification: In situ - Ex situ
  • 12. Belghiti J. et al., Gastroenterol Clin Biol 1991. In Situ - Ante situm Clarification: In situ - Ex situ
  • 13. Mettre livre Approach to the supra-hepatic IVC: value of ante situm
  • 14. Ante situm provides the surgeon 1) Optimal visualization of the hepatic venous confluence 2) A complete resection of the tumor without transecting the portal triade.
  • 15. Total 166 TVE: 66% R0: 87% 11/148: 7.4% 61/148: 41% Tube: 43% Relevant Reported Series of Combined Liver and IVC Resections Guerrini, Intern J Surg 2015
  • 16. Hypothermic perfusion - portal route - UW solution Liver Resection with TVE and Hypothermic Perfusion of the Liver and Veno-Venous Bypass Preliminary Experience 20 cases Bypass UW 4°C Our experience and lessons learned: Preliminary experience
  • 17. Azoulay, et al., Ann Surg 2005 • 1- Total vascular exclusion of the liver > 60 minutes is better tolerated when performed under hypothermic perfusion • 2- Mortality tends to be lower and morbidity is significatively lowered following TVE under hypothermic perfusion compared to standard TVE • 3- The need for portal vein embolization, the maximum diameter of the lesion, and a planned vascular reconstruction are independent predictors of TVE > 60 minutes
  • 18. Patients and methods TVE and Hypothermic Perfusion of the Liver: Further experience 1998 - 2010 2455 Hepatectomies Vascular Exclusion 391 (15.9%) No Vascular Exclusion 2064 (84.1%) Vascular Exclusion Without Caval Clamping 227 (9.2%) Vascular Exclusion With Caval Clamping 164 (6.7%) Hypothermic Perfusion 77 (3.1%) Without Hypothermic Perfusion 87 (3.6%) Bypass UW 4°C
  • 19. Disease Colo-rectal metastases Mass forming cholangiocarcinoma Hepatocellular carcinoma Klatskin Benign Tumor Other TVE with Hypothermia 77 cases 31 (40.2%) 22 (26.6%) 10 (13%) 2 (2.6%) 5 (6.5%) 7 (11%)s Patients and methods Bypass UW 4°C TVE and Hypothermic Perfusion of the Liver: Further experience
  • 20. « Biological tolerance » Azoulay D, et al., Ann Surg 2014
  • 21. Azoulay D, et al., Ann Surg 2014
  • 22. Azoulay D, et al., Ann Surg 2014
  • 23. Three independent predictors of 90-Day mortality • CCI 3 or more • Maximum tumor size >10 cm • Presence of 50/50 criteria  Expected  Not controlable  Too late… So What? Azoulay D, et al., Ann Surg 2014
  • 24. CRLMets, n = 33/36 available Updated survivals 94 cases (unpublished)
  • 25. HCC, n = 15 Updated survivals 94 cases (unpublished)
  • 26. IHCC, n = 26 Updated survivals 94 cases (unpublished)
  • 27. Veno Venous Bypass CHB Experience: ⌁Zero severe problem / hundreds of VVBs Navez et al., HPB in press VVB Yes n = 13 96 600 3 (23%) 30% 0 15% 16 VVB No n = 14 75 1750 2 (14%) 50% 29% 64% 19 Variable Duration Vasc Exclusion, min Blood Loss, mL Mortality Severe morbidity Ascites Resp. complications Hospital stay, days p value 0.18 0.01 0.6 0.4 0.04 0.01 0.35
  • 28. 12 14 16 18 20 22 24 26 28 PAP mm Hg 4.5 5 5.5 6 6.5 7 7.5 8 CO L/min 4 5 6 7 8 9 10 RAP mm Hg NS NS NS NS NS NS 7.25 7.3 7.35 7.4 7.45 7.5 Arterial blood pH 34 35 36 37 Central Temperature °C S S NS S 70 75 80 85 90 95 100 105 NS S MAP mm Hg before during after before after during Liver resection under total vascular exclusion Veno-Venous Bypass = Hemodynamical stability Reminder: hemodyn intolerance = 17% in Belghiti et al., Ann Surg 1996
  • 29. Azoulay D, et al., Liver Transpl 2019 Obviates cumbersome portal canula
  • 30. Azoulay D, et al., Int Care Med 2019
  • 31. Azoulay D, et al., HBSN 2014 Personal experience = 8 cases
  • 32. Ex situ = Portal triade reconstruction needed Ex Situ Resection Oldhafer KJ, et al., Surgery 2000 Pichlmayr R, et al., Br J Surg 1990
  • 33. Nagino, et al., Ann Surg 2010 50 cases of Klatskin tumors 1997 - 2009 Biliary drainage 45 cases (90%) VVB = ZERO, Hypothermic perfusion = ZERO Operative mortality = 1 case (2%) Operative Morbidity = 54 % (27 patients)
  • 34. « In earlier studies from Pichlmayr et al. … morbidity and mortality rates were close to 30%. In the past 15 years, we were able to reduce this mortality rate to 12.5% in favor of the ante situm liver resection... » Oldhafer, et al., Langenbeck’s Arch Surg 2018
  • 35. Zawistowski zt al., Surgery 2021 in press Govil al., Indian J Gastroenterol 2013 Balmas-Geaorge al., Langenbeck’Arch Surg 2021 Balmas-Geaorge al., Langenbeck’Arch Surg 2020
  • 36. In situ vs. Ex situ ? Review (personal) vs. vs Hypothermic perf for malignancy Postoperative Mortality 12.7% 27.7% Including 8 cases salvage transplantation… vs. 13% 20% Including 8 cases of salvage transplantation…
  • 37. Left PV invaded Left branch HA free Biliary dilatation
  • 40. IVC replaced/PTFE graft PV reconstruction Biliary drain S3 S2
  • 41. LT LR LT LR LT LT LR LR LR LR Oslo Low & High Tumor Burden: « Selected CRLM with low Oslo Score and high Tumor Burden Score could benefit from LT with survival outcomes that are far better than what is achieved by LR. » Lanari J, et al., Transplant Intern 2021
  • 42. In Situ Hepatectomy & Hypothermic Perfusion of the Liver Conclusions (1) • Rare = 3% of highly specialized activity • Planification/ Adaptation ->bypass, cell saver, hypothermic perfusate available • In situ « better » than Ex situ in terms of mortality
  • 43. Conclusions (2) • How to improve strategy? • Improve patient-doctor decision process for this type of surgery: difficult in the current era of mini- invasive approach & ERAS…? • Define the place of salvage liver transplantation ? In Situ Hepatectomy & Hypothermic Perfusion of the Liver