Ex Vivo Liver Resection Followed by Autotransplantation to a Patient With Advanced Alveolar Echinococcosis With a Replacement of the Retrohepatic Inferior Vena Cava Using Autogenous Vein Grafting

Alveolar echinococcosis (AE) of the liver is a rare disease. In advanced cases of this parasitic disease, the inferior vena cava (IVC) can be invaded; in these cases, the optimal treatment is liver transplantation and replacement of the IVC. Considering the donor shortage and the drawbacks of immunosuppressive therapy, ex vivo liver resection followed by autotransplantation may be the first choice for these patients. We report the first case of advanced AE successfully treated by an ex vivo liver resection, followed by autotransplantation with a replacement of the retrohepatic IVC using autogenous vein grafting. This graft included the following regions: the bilateral great saphenous vein, part of the retrohepatic inferior vena and the middle hepatic vein with no invasion, the inferior mesenteric vein, and part of the side wall of the infrahepatic vena cava. This patient had an uneventful postoperative recovery; currently, she has been enjoying a normal life and is 12 months postoperative with no immunosuppressive therapy or AE recurrence. In conclusion, ex vivo liver resection followed by autotransplantation with a replacement of the retrohepatic IVC using autogenous vein grafting might be a useful surgical practice for advanced AE. (Medicine 94(7):e514) Abbreviations: AE = alveolar echinococcosis, DCD = donation tao, PhD, Yan Lun Jichun, PhD, d Yuan Ding, MD INTRODUCTION H epatic alveolar echinococcosis (AE) is a rare but potentially life-threatening parasitic disease that is characterized by a slow-growing neoplasm with infiltrative growth that includes strong adhesions and invasions to the adjacent structures. It has also been characterized as a chronic, serious, and sometimes lethal parasitic infection that is caused by Echinococcus multilocularis. Although medical therapy may stabilize the lesion in some cases, a definitive cure can only be obtained by a liver resection of the localized masses. Most cases are impossible or difficult to resect due to an advanced stage, which is characterized by an infiltration of the retrohepatic vena cava and biliary tract; only 35% of patients are eligible for partial liver resection, and liver transplantation should be accepted as a life-saving treatment option in patients with AE for whom there is no other medical or surgical treatment option. However, liver transplantation in patients with hepatic AE remains highly controversial due to shortages of donor organs. Ex vivo liver resection followed by autotransplantation was pioneered by Rudolf Pichlmayr in 1999, who tried to open a new platform for unresectable hepatobiliary malignancies and explore new pathways for liver surgery. Ex vivo liver resection and hepatic autotransplantation allow the treatment of otherwise unresectable hepatic AE and expand the scope of liver surgery. However, for patients with invasions to the inferior vena cava (IVC), the only treatment option is liver transplantation with a replacement of the IVC, and then, there is a question as to which of the following is the best choice to reconstruct the IVC: a cryopreserved venous graft, an artificial vessel or an autogenous vein. In our present study, we present an end-stage liver AE patient who benefited from an ex vivo resection of the liver followed by autotransplantation of the AE-free lateral segments with a replacement of the vena cava using a combination of autogenous vein grafting including the bilateral great saphenous vein, the inferior mesenteric vein, part of the side wall of the infrahepatic vena cava, part of the retrohepatic inferior vena and the middle hepatic vein with no invasion.