Objective To discuss the safety and feasibil ity of treating complex renal aneurysm with ex vivo aneurysmectomy and renal revascularization and renal autotransplantation after hand-assisted retroperitoneoscopic nephrectomy. Methods In October 2006, one male patient with complex renal aneurysm was treated. The preoperative color Doppler ultrasonograph, CT and DSA showed that there was an aneurysm (3.4 cm × 4.3 cm × 4.5 cm) located in the main renalartery bifurcation and its five branches of the left kidney. The patient had a history of hypertension with no response to treatment. After successful hand-assisted retroperitoneoscopic nephrectomy, the kidney off-body was perfused by the renal irrigating solution immediately to protect the kidney. Then ex vivo aneurysmectomy and renal artery revascularization were performed, the renal artery was reconstructed with an autologous right internal il iac artery. The reconstructed left kidney was re-implanted into the right il iac fossa. Results The operation was successful and the patient recovered without perioperative complications. The postoperative renal function was normal and the color Doppler ultrasonograph showed that the blood circulation in the transferred renal artery of the right il iac fossa and its branches was smooth, the blood circulation of the renal venous was smooth and no stenosis in the ureter 2 weeks after operation. Thirteen months follow-up showed the blood pressure was recovered to normal and the renal function was normal. Conclusion The method of ex vivo aneurysmectomy and autotransplantation is safe, feasible and minimally invasive for treating complex hilar renal artery aneurysms.
Objective To decrease the operative difficulty, with the purpose of looking for an orthotopic liver autotransplantation model which not only materializes the liver transplantation but also possesses higher survival rate. Methods This model was established via portal vein perfusion in thirty rats, and from which the result of the liver after perfusion, the operative time and the survival rate were observed. Liver tissues were researched at 24 h after operation under the light microscope. Results This model was easy to be perfused, the operative time was (48±3.0) min and the survival rate was 96.7% (29/30). The structure of hepatic tissue was basically normal with a little hydropic degeneration under the light microscope. Few erythrocytes residual occurred in the interlobular arteries under the light microscope. Conclusion The orthotopic liver autotransplantation model via portal vein perfusion has an exclusively blockage pattern which possesses a higher survival rate. It prevents the injury of immunological rejection and purely reflects the hepatic ischemia-reperfusion. But it is better to be applied in the non-hepatic artery anastomosis or the research nothing to do with the hepatic artery because the hepatic artery does not have sufficient perfusion.
Objective To summarize the methods, safety, and efficacy of the ex vivo liver resection followed by autotransplantation in the treatment of advanced hepatic alveolar echinococcosis (HAE). Method A retrospective analysis of clinical data and follow-up data in 21 cases who received ex vivo liver resection followed by autotransplantation in the treatment of HAE from February 2014 to December 2016 in West China Hospital was performed. Results All the patients successfully underwent ex vivo liver resection followed by autotransplantation and no death happened during operation. The median weight of remnant liver was 701.4 g (360–1 300 g), the average operation time were 13.6 h (9.4–19.5 h), the anhepatic phase time were 180–455 min with median of 314 min. The average of intraoperative blood loss were 2 379 mL (1 200–6 000 mL). The average of patients entered red blood cell suspension were 10.6 u (0–39.5 u), the average of fresh frozen plasma were 1 377 mL (0–6 050 mL) , of which 7 patients received autologous blood transfusion, with average of 1 578 mL (500–3 700 mL). The average of postoperative hospital stay were 23.5 days (4–51 days). Postoperative complications occurred in 12 patients during hospitalization, and 4 cases of postoperative complications were in grade Clavien-Dindo Ⅲ or above, 2 cases of grade Ⅴ (died). During the follow-up period, 19 patients were followed for a median of 16.2 months (3–38 months), no HAE recurrence or metastasis was found, only 1 patient were lost follow-up after surgery for 12 months. Massive ascites and hyponatremia were found in 1 patient who was diagnosis as left hepatic vein stenosis at the end of the 3 months after operation. The patient was cured after interventional treatment of hepatic vein stent implantation and angioplasty. Conclusions The ex vivo liver resection followed by autotransplantation provides radical treatment for patients with advanced HAE, but the surgery is difficult and has high risk of postoperative complications. The detailed preoperative evaluation, intraoperative pipeline reconstruction reasonably, and fine postoperative management can improve the patient’s survival, and reduce the rate of complications.
Objective To explore feasibility and safety of ex vivo liver resection and autotransplantation in treating end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein. Methods The patient was diagnosed with the end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein. The ultrasonography, computed tomography, and magnetic resonance imaging were used to access the characteristics of the lesions and the extent of involvement of the portal vein and its branches. The liver model was reconstructed using a three-dimensional imaging data analysis system (EDDA Technology, Inc. USA), the remnant liver volume and the extent of involvement of the first hepatic hilum were recorded. Then the multidisciplinary team repetitively discussed the risks and procedures involved in the surgery. Finally, the ex vivo liver resection and autotransplantation was proposed. Results The preoperative evaluation showed the patient had a large intrahepatic lesion which severely invaded the retrohepatic inferior vena cava, the right hepatic vein, and the middle hepatic vein and were completely occluded, the left hepatic vein was partially invaded, and the portal vein was spongiform. The remnant liver volume was 912 mL, the ratio of residual liver volume to standard liver volume was 0.81. The preoperative liver function Child-Pugh score was grade A. The ex vivo liver resection and autotransplantation was successfully managed according to the expected schedule. The autografts (made by patient’s great saphenous vein) were used to reconstruct the hepatic vein and portal vein, and the retrohepatic inferior vena cava was not reconstructed. The patient recovered well and was discharged on day 20 after the operation. Conclusions Ex vivo liver resection and autotransplantation could successfully be applied in treating patient with end-stage hepatic alveolar echinococcosis combined with secondary cavernous transformation of portal vein. Adequate preoperative assessment and management of the first hepatic hilum are key to this operation.
ObjectiveTo summarize short-term and long-term effects of ex vivo liver resection followed by autotransplantation (Abbreviation: autotransplantation) in treatment of advanced hepatic alveolar echinococcosis (HAE).MethodThe clinical data and follow-up data of 17 patients with advanced HAE who underwent autotransplantation from November 2016 to July 2019 in the Ganzi Tibetan Autonomous Prefecture People’s Hospital were retrospectively analyzed.ResultsThe autotransplantations were performed successfully in the 17 patients with advanced HAE. Ten patients underwent the inferior vena cava (IVC) reconstruction with autologous saphenous veins, 5 patients underwent the artificial revascularization, 1 patient underwent the direct anastomosis of the original IVC, and 1 patient didn’t reconstructed (the retroperitoneal collateral circulation was abundant). The mean liver graft mass was 681.3 g (365–1 350 g) and operation time was 11.5 h (9–16 h). The median anhepatic period was 312 min (175–450 min), blood loss was 2 000 mL(950–4 500 mL), red blood cell suspension transfusion was 6.4 U (1–20 U), and fresh frozen plasma was 1.1 L (0.8–2.0 L). The postoperative hospital stay was 5 to 45 d with an average of 25.6 d. There were 4 patients with the postoperative hepatic enveloping effusion, 1 patient with bile leakage, and 1 patient with bile duct stenosis. All of them were treated and cured, and no death occurred. The follow-up time of 17 patients was 3 to 35 months with an average of 9.5 months, no recurrence of HAE and distant metastasis were observed.ConclusionsIn highlands, autotransplantation in treatment of advanced HAE patients with different IVC reconstruction is satisfactory, but it has a higher risk and is difficult. Choice of intraoperative reconstruction materials, judgment of posterior peritoneal collateral circulation, presence or absence of tension in end-to-end anastomosis of the IVC require precise consideration. At the same time, anticoagulation therapy and complications management are difficult, and it is only suitable for plateau medical center with rich experience.
ObjectiveTo explore the feasibility and safety of modified semi-ex vivo small intestinal autotransplantation (IAT) in patients with distal cholangiocarcinoma (CC) involving mesenteric root. MethodThe clinicopathologic data of the patient with relapse after CC surgery admitted to Sichuan Provincial People’s Hospital on October 2022 were retrospectively analyzed. ResultsThe patient was a 40 years old male. The preoperative imaging showed that the superior mesenteric artery (SMA) and jejunal artery was surrounded by the tumor. The preoperative condition was good and the heart, lung, liver, and kidney functions were normal. The patient could tolerate surgery, then the modified semi-ex vivo IAT was performed. The patient recovered well after surgery and discharged on the 14th postoperative day. The postoperative pathological diagnosis result showed that it was CC. The patient was well and without recurrence or metastasis during following-up in the outpatient service for 5 months until April 2023. ConclusionsFrom the retrospective analysis of this case, it can be realized that the modified semi-ex vivo IAT for patients with tumor involving themesenteric root, it is safe and feasible. A treatment option can be provided for such patient.
ObjectiveTo explore the safety and practicality of intestinal autotransplantation (IATx) combined with radical tumor resection in the treatment of intraperitoneal tumors involving vital blood vessels. MethodThe research progress on indications, preoperative evaluation, ex vivo organ preservation techniques, and mesenteric vascular reconstruction techniques for IATx from January 1996 to August 2023 both domestically and internationally was reviewed. ResultsThe IATx had become a feasible surgical option for the patients with intraperitoneal tumors involving vital blood vessels (more than 180° involving the root of the superior mesenteric artery). The related studies had identified that the intraperitoneal tumors involving vital blood vessels mainly originated from the pancreas, mesentery, and retroperitoneum. Establishing a multidisciplinary team for preoperative assessment of IATx could aid to establish a valuable diagnostic and treatment system. The keypoints of IATx mainly included IATx preparation (cutting and ligating mesenteric blood vessels), in vivo tumor resection, cryopreservation of intestine in vitro, vascular and gastrointestinal reconstruction after IATx, which was different viewpoints in the different literature, such as the selection of in vivo/in vitro tumor resection, mesenteric vascular reconstruction, and portal or vena cava drainage. However, there was a consensus that the optimal solution for ex vivo organ preservation technology was improved solutions relevant to UW. At present, the hot ischemia time of intestine graft was shortened, the incidence of postoperative intestinal graft loss was reduced, and the postoperative survival of patients was gradually extended. But there were still some unresolved complications, such as early graft loss, pancreatic leakage, delayed gastric emptying, postoperative bleeding, etc. ConclusionsIATx combined with tumor resection for intraperitoneal tumors involving vital blood vessels is feasible through carefully preoperative evaluation and surgical planning, which could provide a good clinical and prognostic result. But this operation requires higher technical requirements and might only be performed in centers with rich experience in intestinal transplantation.
ObjectiveTo summarize and analyze the application of ex vivo liver resection and autotransplantation (ELRA) in the treatment of hepatobiliary diseases. MethodThe related literature about ELRA used to treat various hepatobiliary space-occupyingdiseases at home and abroad in recent years was comprehensively searched and summarized. ResultsELRA had overcome the limitations of limited operational space in traditional surgery for the treatment of hepatobiliary space-occupying diseases reduced dependence on donor livers, and avoided post-transplant rejection. It had been applied in the treatment of hepatic alveolar echinococcosis, liver cancer, cholangiocarcinoma, and rare liver space-occupying diseases. ConclusionsWith the maturation of ELRA techniques and the continuous improvement of ex vivo liver perfusion technology, along with rigorous preoperative evaluation and meticulous postoperative management, postoperative complications of ELRA have significantly decreased compared to the initial stages of its application. By strictly adhering to surgical indications, this procedure is expected to be used treatment in an increasing number of hepatobiliary space-occupying diseases.
ObjectiveTo investigate the risk factors affecting severe postoperative complications (Clavien-Dindo classification Ⅲa or higher) in patients with end-stage hepatic alveolar echinococcosis (HAE) underwent ex vivo liver resection and autotransplantation (ELRA), and to develop a nomogram prediction model. MethodsThe clinical data of end-stage HAE patients who underwent ELRA at the West China Hospital of Sichuan University from January 2014 to June 2024 were retrospectively analyzed. The logistic regression was used to analyze the risk factors affecting severe postoperative complications. A nomogram prediction model was established basing on LASSO regression and its efficiency was evaluated using receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis. Simultaneously, a generalized linear model regression was used to explore the preoperative risk factors affecting the total surgery time. Test level was α=0.05. ResultsA total of 132 end-stage HAE patients who underwent ELRA were included. The severe postoperative complications occurred in 47 (35.6%) patients. The multivariate logistic analysis results showed that the patients with invasion of the main trunk of the portal vein or the first branch of the contralateral portal vein (type P2) had a higher risk of severe postoperative complications compared to those with invasion of the first branch of the ipsilateral portal vein (type P1) [odds ratio (OR) and 95% confidence interval (CI)=8.24 (1.53, 44.34), P=0.014], the patients with albumin bilirubin index (ALBI) grade 1 had a lower risk of severe postoperative complications compared to those with grade 2 or higher [OR(95%CI)=0.26(0.08, 0.83), P=0.023]. Additionally, an increased total surgery time or the autologous blood reinfusion was associated with an increased risk of severe postoperative complications [OR(95%CI)=1.01(1.00, 1.01), P=0.009; OR(95%CI)=1.00(1.00, 1.00), P=0.043]. The nomogram prediction model constructed with two risk factors, ALBI grade and total surgery time, selected by LASSO regression, showed a good discrimination for the occurrence of severe complications after ELRA [area under the ROC curve (95%CI) of 0.717 (0.625, 0.808)]. The generalized linear regression model analysis identified the invasion of the portal vein to extent type P2 and more distant contralateral second portal vein branch invasion (type P3), as well as the presence of distant metastasis, as risk factors affecting total surgery time [β (95%CI) for type P2/type P1=110.26 (52.94, 167.58), P<0.001; β (95%CI) for type P3/type P1=109.25 (50.99, 167.52), P<0.001; β (95%CI) for distant metastasis present/absent=61.22 (4.86, 117.58), P=0.035]. ConclusionsFrom the analysis results of this study, for the end-stage HAE patients with portal vein invasion degree type P2, ALBI grade 2 or above, longer total surgery time, and more autologous blood transfusion need to be closely monitored. Preoperative strict evaluation of the first hepatic portal invasion and distant metastasis is necessary to reduce the risk of severe complications after ELRA. The nomogram prediction model constructed based on ABLI grade and total surgery time in this study demonstrates a good predictive performance for severe postoperative complications, which can provide a reference for clinical intervention decision-making.