Journées chirurgie 2022

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

38. PV
LPV
RPV

39. PV
LPV
RPV

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