Ex-situ Liver Surgery for Tumors and Liver Transplant Complications – A Single Center Experience

Purpose: Tumors involving vital hepatic structures may prohibit safe resection utilizing conventional surgical techniques and thereby render the patient as non-resectable. Ex-situ surgery with extracorporeal cooling and bench surgery can potentially overcome many of these limitations and provides optimal conditions for vascular reconstruction but at the risk of higher surgical complexity and increased postoperative morbidity and mortality. Similarly, these techniques may be useful in vascular complications after liver transplantation. We herein report our 20-year experience with these techniques. Methods: Patients were followed prospectively, and endpoints were overall survival, 90 day mortality, postoperative complications and need for rescue liver transplantation. Complications were registered according to the Clavien Dindo classification and a score of 3a or more was considered a major complication Results: Thirty-three patients, (19 females) median age 48 years (8-73) were included. Ex-situ resection and auto-transplantation were performed in 25 and ante-situm utilized in 8. Primary cancers were the indication in 15 patients (sarcomas in 8/15), metastases in 12 (colorectal in 8/12), and 6 patients were operated for benign conditions (3 giant hemangiomas, 3 outflow obstructions after liver transplantation). Vascular reconstruction was necessary in all cases (vena cava :29, Hepatic veins:20). Major complications were observed in 81%, most frequent pleural effusion (70%), vascular complication (33%) and biloma (21%). The 90-day mortality was 3,3%. Three patients required rescue liver transplant due to post-resection liver failure in 2 and prosthetic graft infection in 1. There was no mortality in the benign cases. The median survival was 53 months in primary tumors and 22 months in metastases. The 10-year survival was 40% in primary tumors. Conclusion: Ex-situ liver surgery is feasible in tumors requiring complex vascular reconstructions and may be useful in demanding complications after transplant. Careful patient selection is essential due to high complication rate. Patients with primary liver tumors may have long-term survival benefit.