Total vascular exclusion in pediatric hepatectomy: reducing hemorrhage without added morbidity.

BACKGROUND

Major hepatectomy in children carries distinct risks and challenges, with intraoperative hemorrhage being a critical determinant of morbidity and survival. Total vascular exclusion (TVE) provides complete vascular control, but its use in adults is associated with high morbidity. Evidence for pediatric hepatectomy is lacking.

METHODS

A single-center study of all children (<18 years) undergoing major hepatectomy between 2013 and 2023 was performed. Patients were grouped by TVE use. Primary outcomes were major complications (Clavien-Madadi ≥ III) and posthepatectomy liver dysfunction. Secondary outcomes included CCI, blood loss, transfusion, renal function, hospital stay, and oncologic outcomes.

RESULTS

A total of 125 patients were included (68% with hepatoblastoma). TVE was applied in 67 children (53.6%) with a median duration of 18 min. No episodes of hemodynamic instability occurred during TVE. Outcomes including major complications (6.0% TVE vs. 6.9% non-TVE, p = 1.000), as well as intraoperative blood loss and transfusion, did not differ significantly between the groups. No patient developed clinically relevant posthepatectomy liver failure or renal dysfunction.

CONCLUSIONS

This is the largest series of children undergoing hepatectomy using TVE. In contrast to adult liver surgery, where adverse physiological effects constrain its use, TVE can be safely performed in children, without increasing perioperative morbidity.