Salvage Ex Situ Hepatectomy With Liver Autotransplantation for Recurrent Intraductal Papillary Neoplasm of the Bile Ducts (IPNB): A Case Report.

INTRODUCTION: Locally advanced hepatic tumors involving the hepatic veins and inferior vena cava (IVC) represent a major surgical challenge and are often considered unresectable using conventional in situ techniques. In such settings, ex situ hepatectomy with liver autotransplantation emerges as an extreme yet potentially curative strategy that combines oncologic liver surgery and transplant principles. By enabling total vascular exclusion, hypothermic perfusion, and ex situ vascular reconstruction on the bench, this technique allows radical resections with controlled management of complex vascular invasion. Although rarely indicated, it may offer a salvage option for carefully selected patients with recurrent disease and otherwise limited therapeutic alternatives.

CASE REPORT: A 64-year-old woman with a history of left hepatectomy for intraductal papillary neoplasm of the bile duct (IPNB) with cystic degeneration developed recurrent disease in the caudate lobe, with intimate proximity to the major vascular structures of the right hemiliver. Curative-intent salvage ex situ hepatectomy with liver autotransplantation was performed without venovenous bypass, using a temporary portocaval shunt for hemodynamic stability. The liver was perfused with Custodiol solution under hypothermic conditions, followed by ex situ caudate lobe resection with meticulous dissection of the lesion from the right hepatic vein, right portal vein, and right hepatic duct. A large V5 hepatic vein branch was reconstructed using iliac vein allograft. Total ischemia time was 229 minutes and operative time was 625 minutes. After revascularization, the graft showed good aspect without reperfusion syndrome. Histopathology revealed recurrent IPNB with high-grade dysplasia and negative margins. The patient recovered well and was discharged home on postoperative day 15.

CONCLUSION: Ex situ hepatectomy with liver autotransplantation is a feasible salvage therapy for recurrent hepatic tumors in anatomically complex locations,enabling radical resections and favorable functional outcomes in specialized centers.