Urological Note
Ex vivo liver resection with replacement of inferior vena cava without the use of cardiopulmonary bypass in a patient with metastatic adrenocortical carcinoma
Stipislav Jadrijević M.D., Ph.D.,1,2 Oliver Šuman M.D.,1 Daniel Martin Jakus M.D.,1 Pavo Kostopeč M.D., Nataša Višković Filipčić M.D.3 and Karin Zibar M.D., Ph.D.4
Abbreviations & Acronyms
ACC = adrenocortical carcinoma IVC = inferior vena cava
1Division of Transplantation Surgery, Department of Surgery, University Hospital Merkur, Zagreb, 2School of Medicine, University of Split, Split, 3Department of Anesthesiology, University Hospital Merkur, and 4Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Zagreb, Croatia sumanoliver@yahoo.com DOI: 10.1111/iju.13248
ACC is a rare, aggressive tumor with an annual incidence of one to two per 1 000 000 popu- lation.1 Five-year survival rate varies from 16% to 40%.2
A 22-year-old women presented with progressive virilization symptoms for the past 3 months. Endocrinological evaluation showed glucocorticoid and androgen hypersecretion, and an abdominal computed tomography heterogeneous mass 15 x 10 cm in size, which was arising from the right adrenal gland with tumor thrombi in the IVC, and multiple liver metas- tases (Fig. 1a).
Intraoperative evaluation: After the liver mobilization, the primary adrenocortical tumor was shown to be 18 x 12 x 9 cm in size, with multiple liver metastases and extension to the retrohepatic IVC. The diaphragm and pericardium were incised, and the IVC was found to be completely clotted with tumor extension from the influence of the renal veins to the right atrium. The tumor mass was resected and removed, followed by skeletonization of the hepatoduodenal ligament. The common bile duct, proper hepatic artery and portal vein were transected. The IVC was clamped next to the influence of the renal veins and on the influence to the right atrium. Once all the hepatic vessels were transected, the liver was removed
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together with the clotted part of the IVC without the use of a cardiopulmonary bypass (Fig. 1b). The liver was cold per- fused with University of Wisconsin solution on the backtable and preserved in a box with ice.
IVC reconstruction: The IVC was resected and recon- structed with a combination of three grafts, with a total length of 15 cm. One graft was the internal jugular vein autograft. The other two allografts were organ donor iliac veins from our hospital bank. At first, the graft was anastomosed to the right atrium of the beating heart, then to the proximal part of the IVC (Fig. 1c). After IVC reconstruction, the portal vein was anastomosed to the reconstructed graft in order to create a porto-caval shunt.
Ex vivo liver resection: The liver segments II and III were ex vivo resected, and multiple metastases from segments IV- VIII were removed. The hepatic veins were anastomosed to the graft. The porto-caval shunt was occluded and the porto- portal reanastomosis was made. The liver was flushed with 400 mL of blood. The hepatic artery re-anastomosis was made. The common bile duct reanastomosis was made together with Witzle biliary drainage. The operation time was 10 h, the blood loss during the procedure was 21 L.
In order to prevent adrenal crisis as a result of adrenal insufficiency after removing a cortisol producing tumor, the perioperative patient received intravenous hydrocortisone and saline infusions, as well as during the surgical procedure. During the rehabilitation, the dosage was decreased and con- verted to oral, until a maintenance dose was achieved.
Postoperative course: On the sixth day, hepatic artery thrombosis was revealed - it was resected and reconstructed with the graft of the donor artery from our hospital bank. Then, 19 days later, a new exploration was made because of a transverse colon perforation. The colon was sutured and a peritoneal lavage carried out. Computed tomography con- firmed a normal patency of the IVC graft (Fig. 1d). Two months later, the patient was transferred to the endo-oncology department for further systemic therapy.
Tumor thrombus extension is a rare presentation of ACC. Although patients with stage IV have distant metastasis, max- imal debulking surgery is a therapeutic option. Intracaval extension of the tumor is not a contraindication for the sur- gery, but contributes to its complexity.3 IVC invasion extend- ing into the right atrium is a rare complication, reported only in several cases, which was resolved using a cardiopulmonary
bypass tumor thrombectomy.4,5 Ex vivo liver surgery is a technique for treatment of complicated liver tumors that are unresectable by conventional methods.
In the present case, a patient with metastatic ACC was con- sidered for resection of liver metastases and IVC. The decision for ex vivo liver resection was made during the surgical explo- ration. Hepatic vein tumor thrombosis with IVC thrombosis is an indication for ex vivo liver surgery,6 because it is difficult to carry out R0 resection by another technique for this tumor loca- tion.7 Another problem is the duration of vascular clamping during a normal resection. To our knowledge, this is the first case of a tumor resection with ex vivo liver resection and auto- transplantation with replacement of IVC using multiple vein grafting, without using a cardiopulmonary bypass, being car- ried out as a successful procedure in a patient with ACC.
Acknowledgments
The patient gave consent for us to present this case. The pro- tocol for the research project was approved by a suitably con- stituted ethics committee of the institution within which the work was undertaken, and it conforms to the provisions of the Declaration of Helsinki.
Conflict of interest
None declared.
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