Two-Stage Hepatectomy for Cholangiocarcinoma Under Total Vascular Exclusion with Veno-venous ECMO Bypass and Controlled Closed-loop In Situ Hypothermic Oxygenated Perfusion of the Liver: The Hannover CLIP-Concept.

Abstract

Total vascular exclusion (TVE) enables the resection of centrally located liver tumors but remains associated with considerable intra- and perioperative morbidity. We present the Hannover Modification of TVE, which combines veno-venous extracorporeal membrane oxygenation (vvECMO) and a closed-loop in situ hypothermic oxygenated perfusion (CLIP) of the liver using the Bridge-to-Life^® VitaSmart system for targeted parenchymal protection. A 62-year-old woman with FGFR2-fused intrahepatic cholangiocarcinoma (iCCA) involving the hepatocaval confluence and all three hepatic veins, previously deemed unresectable, underwent partial ALPPS-preserving segment IVb. One week later, extended right trisectionectomy with reconstruction of the left hepatic vein was performed under TVE. Dual perfusion circuits were established: (1) a portocaval anastomosis was established and systemic and portal venous return was maintained via vvECMO; (2) cold (4 °C), oxygenated HTK solution was infused via a left portal vein catheter, drained through the hepatic veins into the IVC, and recirculated through a caval outflow cannula. The CLIP approach ensured continuous oxygenation and hypothermia of the liver during resection and venous reconstruction without systemic cooling. Operative time was 4 hours and 3 minutes, with 72 minutes of CLIP and 130 minutes of vvECMO. Histopathology revealed a 6.5-cm iCCA (ypT1a, G2) with negative margins (R0). The postoperative course was uneventful, and the patient was discharged on postoperative day 7 with excellent liver function. The Hannover CLIP technique effectively combines controlled, recirculated HOPE with vvECMO. This approach minimizes ischemic injury to the liver, kidneys, and intestines and facilitates safe resection of highly complex central liver tumors under TVE.