Resection of Retrohepatic Inferior Vena Cava Without Reconstruction for Hepatic Alveolar Echinococcosis
Hepatic alveolar echinococcosis (AE) is a severe parasitic disease caused by Echinococcus multilocularis, primarily affecting the liver. The disease is characterized by invasive growth, often involving critical vascular structures, making surgical intervention challenging. This case report describes a unique surgical approach involving the resection of the retrohepatic inferior vena cava (RHIVC) without reconstruction in a patient with advanced hepatic AE. The case highlights the importance of preoperative assessment, the role of collateral circulation, and the feasibility of complex liver resections in managing this condition.
Clinical Presentation and Diagnostic Workup
The patient was a 40-year-old woman who presented with upper left abdominal pain. Initial laboratory tests revealed a hemoglobin level of 112 g/L and an albumin level of 36.8 g/L, both within normal ranges. Importantly, there was no evidence of portal hypertension. Serological tests were positive for three Echinococcus granulosus antigens and one E. multilocularis antigen, confirming the diagnosis of AE.
Computed tomography (CT) imaging revealed a large lesion in the right and caudate lobes of the liver, as well as a smaller lesion in the left lobe. The lesion in the right lobe was particularly aggressive, invading critical vascular structures, including the right hepatic vein, the root of the middle hepatic vein, the right branch of the portal vein, the right hepatic artery, and the inferior vena cava (IVC). Preoperative inferior vena cava angiography further demonstrated complete occlusion of the posterior IVC, with the establishment of multiple collateral circulation pathways. The preoperative indocyanine green retention rate at 15 minutes (ICG R15) was 4%, indicating normal liver function. A volumetric liver CT scan showed a left hemiliver volume (segments I–II–III–IV) of 605 cm³, accounting for 54% of the total liver volume of 1121 cm³. The patient’s body weight was 55 kg.
Surgical Planning and Multidisciplinary Assessment
Given the complexity of the case, a multidisciplinary team was assembled to assess the feasibility of surgical intervention. The team concluded that a hepatolobectomy combined with RHIVC resection was the most appropriate approach. An artificial blood vessel was prepared in case IVC vascular replacement became necessary during the procedure. The decision to proceed with RHIVC resection without reconstruction was based on the presence of adequate collateral circulation, as demonstrated by preoperative imaging.
Surgical Procedure
The surgery began with an exploration of the liver, revealing a large vesicular lesion measuring approximately 8 cm × 8 cm in the right lobe. The lesion had invaded the right hepatic vein and extended into the caudate lobe, involving the root of the middle hepatic vein. Additionally, the lesion had a prominent downward extension, invading the right adrenal gland and the IVC. Collateral circulation was observed in the retroperitoneum, particularly above the right kidney. A smaller AE lesion, measuring approximately 4 cm × 4 cm, was also identified in the left lobe.
Before proceeding with liver resection, the surgical team temporarily closed the IVC above the left renal vein for 5 minutes to assess hemodynamic stability. The patient tolerated this maneuver well, with no signs of intestinal congestion or hemodynamic compromise. This confirmed the adequacy of the collateral circulation, allowing the team to proceed with RHIVC resection without reconstruction.
The surgical team then selectively blocked the right portal vein and hepatic artery to minimize blood loss during parenchymal dissection. The liver parenchyma was carefully dissected, and the lesions were excised up to the root of the middle hepatic vein. The lateral wall of the middle hepatic vein was reconstructed and repaired to ensure venous outflow from the remaining liver. The entire procedure lasted 5 hours, and no severe postoperative complications were observed.
Postoperative Considerations and Follow-Up
The successful outcome of this case underscores the importance of preoperative imaging and multidisciplinary planning in managing complex hepatic AE. The presence of adequate collateral circulation was a critical factor in enabling RHIVC resection without reconstruction. This approach not only simplified the surgical procedure but also reduced the risk of postoperative complications associated with vascular reconstruction.
Discussion
Hepatic AE is a challenging condition to manage, particularly when it involves critical vascular structures such as the IVC. The disease’s invasive nature often necessitates extensive surgical resections, which can be complicated by the need for vascular reconstruction. However, as demonstrated in this case, the presence of adequate collateral circulation can obviate the need for vascular reconstruction, making complex liver resections feasible.
Preoperative inferior vena cava angiography is essential for assessing the degree of collateral circulation establishment. In this case, the collateral circulation was primarily concentrated in the peritoneum, above the right kidney, allowing for the safe resection of the RHIVC. Additionally, the protection of functional liver tissue during surgery is crucial. In this case, the team was able to preserve the left hemiliver, which accounted for 54% of the total liver volume, ensuring adequate postoperative liver function.
The excision of the RHIVC without reconstruction represents a safe and feasible approach for patients with hepatic AE and adequate collateral circulation. This approach simplifies the surgical procedure and reduces the risk of complications associated with vascular reconstruction. However, it is essential to carefully assess the degree of collateral circulation preoperatively to ensure the safety and feasibility of this approach.
Conclusion
This case report highlights the successful management of a complex case of hepatic alveolar echinococcosis through a combination of hepatolobectomy and RHIVC resection without reconstruction. The presence of adequate collateral circulation was a critical factor in enabling this approach, underscoring the importance of preoperative imaging and multidisciplinary planning. The excision of the RHIVC without reconstruction represents a safe and feasible option for patients with hepatic AE and adequate collateral circulation, offering a simplified surgical approach with reduced risk of complications.
doi.org/10.1097/CM9.0000000000000297
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