ARTICLE IN PRESS JID: HBPD [m5G;April 16, 2020;14:10] Hepatobiliary & Pancreatic Diseases International xxx (xxxx) xxx Contents lists available at ScienceDirect Hepatobiliary & Pancreatic Diseases International journal homepage: www.elsevier.com/locate/hbpd Letter to the Editor A ten-year experience of inferior vena cava reconstruction for malignancy: The importance of a multidisciplinary approach with hepatobiliary surgery Maria R. Baimas-George a , Ryan C. Pickens a , Jesse K. Sulzer a , Dionisios Vrochides a , John B. Martinie a , David M. Levi b , David A. Iannitti a,∗ a Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 600, Charlotte, NC 28204, United States b Division of Transplant Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, United States To the Editor, Tumor invasion of the inferior vena cava (IVC) through direct erosion is a rare and poor prognostic feature of aggressive hepatic or perihepatic malignancies [1,2]. Literature shows poor response to chemotherapy, such that resection often is the only option for improved survival [3]. Multidisciplinary collaborations can expand technical options; incorporation of transplant techniques has led to successful R0 resections involving difficult vascular reconstruc- tion and extended resections [4,5]. This study describes and ana- lyzes the ten-year collaborative experience of hepatobiliary (HPB) surgeons in management of malignancies involving the perihepatic IVC. A retrospective review was performed of hepatobiliary malig- nancies with involvement of the perihepatic IVC from 2008 to 2018. Primary outcomes were early mortality and survival. Sec- ondary perioperative outcomes included postoperative length of stay (LOS), major complications, readmission, and 90-day mortal- ity. All patients considered for perihepatic IVC resection underwent pre-operative multidisciplinary evaluation and optimization. They were presented at multidisciplinary tumor board involving medi- cal oncology, radio-oncology and surgical oncology. IVC resection is only offered for malignancies in which R0 resection was required for significant improvement in survival. Vascular exclusion is guided by intraabdominal and trans- esophageal ultrasonography. If IVC clamping is not tolerated for infra-diaphragmatic tumors, venovenous bypass is employed with assistance from transplant surgery. For tumors extending to the right atrium, cardiopulmonary bypass is utilized with assistance from cardiothoracic surgery. Tumor location and circumferential involvement dictates IVC re- section approach. Invasion of up to 25% circumference allows for tangential resection with primary repair of venotomy. If thrombus is non-adherent, it can be extracted without resection followed by ∗ Corresponding author. E-mail address: david.Iannitti@atriumhealth.org (D.A. Iannitti). primary repair, even if tumor extends above hepatic veins. If tumor adheres or invades between 25% and 75% of circumference, par- tial resection can be employed but is location dependent. Further, the cavotomy for larger resections may require a bovine pericardial patch. Tumor that involves more than 75% of the circumference is managed with segmental resection. If no evidence of chronic in- frarenal IVC occlusion, reconstruction is required to ensure ade- quate venous drainage and cardiac inflow. Primary circumferential repair is preferred if resection gap is small such that the caval ends can be approximated without tension. Most cases require synthetic polytetrafluoroethylene (PTFE) inter-positional graft. For chronic occlusion of the infrarenal IVC with tumor and/or bland thrombus, reconstruction may not be required due to de- velopment of abdominopelvic collaterals through the azygous- hemiazygous and portomesenteric systems. If no history of ob- structive symptomology, the IVC can be sutured or staple ligated if hemodynamically stable during caval interruption, which will in- crease risk of recurrent venous thrombus, pulmonary embolism, or distal thrombus. Retrohepatic IVC invasion requiring ex-vivo hepatic resection is offered to carefully selected patients with excellent pre-operative performance status. Hepatic explantation, en bloc resection on the backtable, synthetic graft reconstruction of the IVC, and piggy- back auto-transplantation are performed in an overlapping man- ner through collaboration with HPB and transplant surgeons. When necessary to achieve an adequate future liver remnant after hepatic resection, two-staged liver molding with techniques such as asso- ciating liver partition & portal vein ligation for staged hepatectomy (ALPPS) can be employed [6]. We identified 16 patients with perihepatic IVC tumor inva- sion or extension requiring liver resection and/or mobilization with caval repair or reconstruction. Disease included intrahepatic cholangiocarcinoma (n = 4), colorectal liver metastases (n = 2), hepatocellular carcinoma (n = 2), retroperitoneal sarcoma (n = 5), pancreatic adenocarcinoma (n = 1), gastrointestinal stromal hep- atic metastases (n = 1), and neuroendocrine tumor hepatic metas- tases (n = 1). Age at time of surgery ranged from 33 to 76 years, https://doi.org/10.1016/j.hbpd.2020.03.013 1499-3872/© 2020 First Affiliated Hospital, Zhejiang University School of Medicine in China. Published by Elsevier B.V. All rights reserved. Please cite this article as: M.R. Baimas-George, R.C. Pickens and J.K. Sulzer et al., A ten-year experience of inferior vena cava reconstruc- tion for malignancy: The importance of a multidisciplinary approach with hepatobiliary surgery, Hepatobiliary & Pancreatic Diseases International, https://doi.org/10.1016/j.hbpd.2020.03.013