Liver Cancer Surgery | Prof. Qiu Shuangjian (Hepatobiliary Surgery) | CMCS Shanghai

About Prof. Qiu Shuangjian

Prof. Qiu Shuangjian is a leading hepatobiliary surgeon at Zhongshan Hospital, Fudan University — one of China's foremost centres for hepatobiliary oncology, complex liver resection, and multidisciplinary liver tumour management. He specialises in surgical resection and minimally invasive treatment of liver cancer and biliary tract diseases, with particular expertise in complex hepatectomy involving vascular reconstruction, in-situ hypothermic perfusion techniques, and the management of advanced hepatic malignancies with hilar involvement. His clinical philosophy holds that even the most technically demanding liver tumours — those involving the hepatic hilum, major vascular structures, and biliary confluence — can be approached with curative intent when surgical planning is meticulous, multidisciplinary collaboration is comprehensive, and intraoperative technique is precise. His department at Zhongshan Hospital has established one of Shanghai's most experienced programmes for complex liver resection, with a dedicated team whose outcomes in vascular reconstruction and extended hepatectomy are recognised as among the most advanced in China.

Case Overview

A middle-aged Chinese man presented with right upper abdominal pain and jaundice. CT and MRI imaging revealed a massive tumour of the right hepatic lobe — approximately 12 cm in diameter — in intimate contact with the major hilar vessels and with invasion of the bile ducts causing biliary obstruction and jaundice. The tumour's size, location, and vascular involvement placed this case among the most technically demanding in hepatobiliary surgery. Following multidisciplinary team (MDT) discussion involving hepatobiliary surgery, radiology, anaesthesia, and the ICU, the team formulated a surgical strategy incorporating in-situ hypothermic perfusion to extend ischaemic tolerance, right trisectionectomy for complete tumour removal, and reconstruction of the left portal vein, retrohepatic inferior vena cava, and left hepatic vein using prosthetic grafts. The procedure was completed in approximately 10 hours with well-controlled intraoperative blood loss. The patient was transferred to the ICU postoperatively, returned to the general ward on day 6, and was discharged in good condition on postoperative day 13 — with no major complications and progressive normalisation of liver function.

Patient Background

• Name / Nationality: Mr. [Pseudonym] — Chinese male, middle-aged
• Chief Complaint: Right upper abdominal pain and jaundice
• History of present illness: Progressive right upper quadrant pain with onset of jaundice; imaging workup revealed a massive hepatic mass with hilar vascular and biliary involvement. Total bilirubin significantly elevated, consistent with biliary obstruction secondary to tumour invasion of the bile ducts.
• Tumour characteristics:
  • Location: Right hepatic lobe, involving the hepatic hilum
  • Size: Approximately 12 cm in diameter
  • Vascular involvement: Intimate adhesion to major hilar vessels; invasion of the left portal vein, retrohepatic inferior vena cava, and left hepatic vein
  • Biliary involvement: Tumour invasion of the bile ducts causing biliary obstruction and obstructive jaundice
• Liver function: Significantly elevated total bilirubin; hepatic functional impairment confirmed on biochemical assessment
• Surgical risk: High — tumour size, hilar location, vascular involvement, and biliary obstruction each independently increase operative complexity and risk; combined, they represent one of the most challenging presentations in hepatobiliary surgery

Diagnostic Workup

Imaging

• CT of the abdomen with contrast: Massive right hepatic lobe mass, approximately 12 cm; intimate contact with major hilar vascular structures; biliary ductal dilatation consistent with obstruction at the hepatic hilum
• MRI of the liver with hepatobiliary contrast: Characterisation of tumour extent, vascular involvement, and biliary anatomy; assessment of future liver remnant volume and function; vascular invasion of the left portal vein, retrohepatic inferior vena cava, and left hepatic vein confirmed

Biochemical Assessment

• Liver function tests: Significantly elevated total bilirubin; transaminases and synthetic function assessed; future liver remnant functional reserve evaluated
• Tumour markers: AFP and other relevant hepatic tumour markers assessed as part of oncological staging workup

Multidisciplinary Team (MDT) Assessment

• MDT discussion: Hepatobiliary surgery, radiology, anaesthesia, and ICU; comprehensive assessment of tumour resectability, surgical risk, and perioperative management strategy; decision to proceed with in-situ hypothermic perfusion right trisectionectomy with vascular and biliary reconstruction confirmed; individualised perioperative plan formulated

Prof. Qiu's pre-operative assessment: This case represents the intersection of every major technical challenge in hepatobiliary surgery — a 12 cm tumour at the hepatic hilum, with invasion of three major vascular structures and the bile ducts, in a patient with compromised liver function from biliary obstruction. The surgical strategy must achieve complete tumour removal while preserving sufficient functional liver remnant and reconstructing every vascular and biliary structure that the tumour has invaded. In-situ hypothermic perfusion is the key enabling technology: by perfusing the liver with cold preservation solution through the portal vein and hepatic artery, we can extend the liver's tolerance to ischaemia during the period of vascular occlusion required for precise dissection and reconstruction — giving us the time we need to do this operation safely. The multidisciplinary team's involvement from the outset — radiology for precise anatomical mapping, anaesthesia for haemodynamic management, and the ICU for postoperative support — is not optional in a case of this complexity. It is the foundation on which a safe outcome is built.

Treatment Strategy: In-Situ Hypothermic Perfusion Right Trisectionectomy with Vascular and Biliary Reconstruction

The diagnosis was Advanced Hepatic Malignancy with Hilar Vascular and Biliary Involvement in a middle-aged patient with obstructive jaundice and high surgical complexity.

The treatment principle was: complete surgical resection of the right trisection and tumour using in-situ hypothermic perfusion to extend ischaemic tolerance, with reconstruction of the left portal vein, retrohepatic inferior vena cava, and left hepatic vein using prosthetic grafts, and biliary reconstruction to restore unobstructed bile drainage — achieving R0 resection with preservation of the functional liver remnant.

Procedure — In-Situ Hypothermic Perfusion Right Trisectionectomy with Vascular Reconstruction:

• In-situ hypothermic perfusion: Continuous perfusion of 4°C cold preservation solution through the portal vein and hepatic artery in situ — maintaining the liver in a hypothermic state during the period of vascular occlusion required for precise dissection and resection; extending the liver's tolerance to ischaemia and significantly improving the safety margin for complex vascular dissection and reconstruction
• Tumour resection — right trisectionectomy: Meticulous dissection of tumour adhesions to surrounding vascular and biliary structures; complete resection of the right hepatic trisection and tumour en bloc; preservation of the left lateral section as the functional liver remnant
• Vascular reconstruction:
  • Left portal vein reconstruction: Prosthetic graft interposition to restore portal venous inflow to the liver remnant
  • Retrohepatic inferior vena cava replacement: Prosthetic graft replacement of the tumour-invaded segment of the retrohepatic IVC; restoration of systemic venous continuity
  • Left hepatic vein reconstruction: Prosthetic graft reconstruction to restore hepatic venous outflow from the liver remnant
• Biliary reconstruction: Reconstruction of the bile duct to restore unobstructed biliary drainage from the liver remnant; biliary-enteric anastomosis as required
• Total operative time: Approximately 10 hours; intraoperative blood loss well controlled

Treatment Course and Outcomes

Intraoperative

• In-situ hypothermic perfusion right trisectionectomy completed successfully under Prof. Qiu Shuangjian's guidance; complete tumour resection achieved; vascular and biliary reconstruction completed; intraoperative blood loss well controlled; no major intraoperative complications

Postoperative ICU Course (Days 1–6)

• Patient transferred to the ICU immediately postoperatively for intensive monitoring; individualised recovery protocol implemented — vital sign monitoring, infection prevention, nutritional support, and early functional rehabilitation; liver function monitored closely with progressive improvement in bilirubin and synthetic function
• No major postoperative complications — no haemorrhage, no bile leak, no vascular graft thrombosis, no hepatic failure

General Ward and Discharge (Days 6–13)

• Patient transferred to the general ward on postoperative day 6; diet and mobility progressively restored; liver function continuing to normalise
• Comprehensive assessment on postoperative day 13 confirmed good overall condition; discharge criteria met; patient discharged in good condition on day 13

Prof. Qiu's clinical reflection: The outcome of this case — complete tumour resection, successful vascular reconstruction, no major complications, and discharge on day 13 — is the result of meticulous preoperative planning, the enabling technology of in-situ hypothermic perfusion, and the seamless collaboration of the multidisciplinary team. In-situ hypothermic perfusion is what makes this operation possible in a patient with this degree of vascular involvement: without the extended ischaemic tolerance it provides, the time required for precise vascular dissection and reconstruction would exceed the safe limits of warm ischaemia, and the risk of liver failure would be unacceptably high. The reconstruction of three major vascular structures — the portal vein, the inferior vena cava, and the hepatic vein — in a single operation, with preservation of a functional liver remnant sufficient to sustain the patient, represents the current frontier of hepatobiliary surgery. This case demonstrates that with the right team, the right technology, and the right planning, even the most complex liver tumours can be approached with curative intent.

Expert Commentary — Prof. Qiu Shuangjian

1. In-Situ Hypothermic Perfusion: Mechanism, Indications, and the Technical Basis for Extended Hepatectomy with Vascular Reconstruction

In-situ hypothermic perfusion — the continuous perfusion of cold preservation solution through the portal vein and hepatic artery while the liver remains in its anatomical position — is the key enabling technology for complex hepatectomy requiring prolonged vascular occlusion. The fundamental challenge of extended hepatectomy with vascular reconstruction is time: the precise dissection of tumour adhesions to major vascular structures, the resection of the involved vascular segments, and the construction of prosthetic graft anastomoses each require a period of vascular occlusion during which the liver is deprived of its blood supply. Under normothermic conditions, the liver's tolerance to warm ischaemia is limited to approximately 15–20 minutes before the risk of ischaemia-reperfusion injury and hepatic failure becomes clinically significant. In-situ hypothermic perfusion extends this tolerance dramatically: by reducing the liver's metabolic rate through hypothermia, the technique allows vascular occlusion times of one to two hours or more without clinically significant ischaemic injury — providing the surgical team with the time required to perform the complex dissection and reconstruction that the tumour's anatomy demands. The technique requires precise coordination between the surgical and anaesthetic teams: the perfusion circuit must be established before vascular occlusion, the perfusion parameters must be maintained throughout the dissection and reconstruction, and the transition from hypothermic perfusion to reperfusion must be managed carefully to minimise ischaemia-reperfusion injury. In experienced hands, in-situ hypothermic perfusion transforms operations that would otherwise be technically impossible — or associated with unacceptably high rates of hepatic failure — into procedures that can be performed with acceptable operative risk and good functional outcomes.

2. Multidisciplinary Collaboration in Complex Liver Tumour Surgery: The Organisational Foundation of Safe Outcomes

The successful management of complex liver tumours — particularly those involving the hepatic hilum, major vascular structures, and biliary confluence — requires a level of multidisciplinary integration that goes beyond the conventional model of specialist consultation. In cases of this complexity, the contributions of radiology, anaesthesia, and the ICU are not supplementary to the surgical plan — they are constitutive of it. Radiology provides the precise anatomical mapping of tumour extent, vascular involvement, and biliary anatomy that defines the surgical strategy and determines resectability; without high-quality preoperative imaging and expert radiological interpretation, the surgical team cannot plan the vascular reconstruction or define the margins of safe resection. Anaesthesia manages the haemodynamic consequences of major vascular occlusion and reconstruction — maintaining perfusion pressure, managing fluid balance, and supporting the cardiovascular system through the physiological stresses of a 10-hour operation with multiple periods of vascular clamping. The ICU provides the postoperative monitoring and support infrastructure that allows the liver remnant to recover its function in the days following major resection — managing the metabolic consequences of hepatic ischaemia-reperfusion, supporting synthetic function, and detecting and managing early complications before they become life-threatening. The integration of these disciplines — from the preoperative MDT discussion through the intraoperative team coordination to the postoperative ICU management — is the organisational foundation on which safe outcomes in complex liver surgery are built.

3. Clinical Significance: Expanding the Boundaries of Resectability in Advanced Hepatic Malignancy

The successful resection of a 12 cm hepatic tumour with hilar vascular and biliary involvement — with reconstruction of three major vascular structures and discharge on postoperative day 13 — represents a meaningful expansion of the boundaries of resectability in advanced hepatic malignancy. Historically, tumours of this size and location, with this degree of vascular involvement, were considered unresectable — candidates for palliative treatment rather than curative surgery. The development of in-situ hypothermic perfusion, the refinement of vascular reconstruction techniques using prosthetic grafts, and the maturation of multidisciplinary perioperative management have collectively shifted the boundary of what is surgically achievable in hepatobiliary oncology. Each case of this complexity that is successfully resected contributes to the evidence base that defines the limits of safe surgery and informs the selection criteria for future patients. The clinical significance of this case extends beyond the individual patient: it demonstrates that with the appropriate technical infrastructure, multidisciplinary organisation, and surgical expertise, a category of patients previously considered beyond surgical help can be offered a curative treatment option — and that the outcomes achievable at a centre of excellence like Zhongshan Hospital, Fudan University, represent the current standard of what is possible in complex hepatobiliary surgery.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported the patient and family throughout the diagnostic, surgical, and recovery pathway at Zhongshan Hospital, Fudan University, including: priority consultation coordination with Prof. Qiu Shuangjian's hepatobiliary surgery team, with bilingual review of all prior CT, MRI, liver function results, and clinical records; bilingual interpretation throughout the MDT discussion, surgical planning consultation, and all postoperative review appointments; bilingual explanation of the in-situ hypothermic perfusion technique — its mechanism, the rationale for right trisectionectomy, the vascular and biliary reconstruction plan, the expected operative duration, and the postoperative recovery pathway; coordination of preoperative imaging, biochemical assessment, and anaesthetic evaluation with bilingual results communication and clinical summary; bilingual surgical consent process — ensuring the patient and family had a complete understanding of the procedure, the vascular reconstruction strategy, the expected recovery timeline, and the postoperative monitoring plan; postoperative ICU and ward coordination including bilingual communication of recovery milestones, liver function trends, and discharge planning; and long-term oncological follow-up coordination including imaging surveillance scheduling and bilingual communication of surveillance results.

For international patients with complex liver tumours — including those with hilar vascular involvement, biliary obstruction, or disease previously considered unresectable — Prof. Qiu Shuangjian's team at Zhongshan Hospital, Fudan University, offers access to one of China's most advanced hepatobiliary surgery programmes. CMCS ensures that expertise is accessible: in the patient's language, with every step of the diagnostic, surgical, and surveillance pathway coordinated and communicated clearly, from the first specialist consultation through long-term oncological follow-up.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.