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Understanding Local Hemodynamic Changes After Liver Transplant: Different Entities or Simply Different Sides to the Same Coin? Transplant Direct 2022; 8:e1369. [PMID: 36313127 PMCID: PMC9605796 DOI: 10.1097/txd.0000000000001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/13/2022] [Accepted: 06/28/2022] [Indexed: 12/02/2022] Open
Abstract
Liver transplantation is an extremely complex procedure performed in an extremely complex patient. With a successful technique and acceptable long-term survival, a new challenge arose: overcoming donor shortage. Thus, living donor liver transplant and other techniques were developed. Aiming for donor safety, many liver transplant units attempted to push the viable limits in terms of size, retrieving smaller and smaller grafts for adult recipients. With these smaller grafts came numerous problems, concepts, and definitions. The spotlight is now aimed at the mirage of hemodynamic changes derived from the recipients prior alterations. This article focuses on the numerous hemodynamic syndromes, their definitions, causes, and management and interconnection with each other. The aim is to aid the physician in their recognition and treatment to improve liver transplantation success.
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Kuramitsu K, Kido M, Komatsu S, Tsugawa D, Gon H, Fukushima K, Urade T, So S, Mizumoto T, Nanno Y, Yamashita H, Goto T, Yanagimoto H, Asari S, Ajiki T, Toyama H, Fukumoto T. Standardization of the Side-to-Side Cavo-Caval Anastomosis in Orthotopic Liver Transplantation Based on the Causal Analysis of Outflow Obstruction. Transplant Proc 2021; 53:2934-2938. [PMID: 34756469 DOI: 10.1016/j.transproceed.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 08/31/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although liver transplantation is widely accepted as the therapeutic strategy for end-stage liver failure, complication of hepatic venous outflow obstruction remains lethal. Currently, ensuring a single wide orifice in both the graft and recipient inferior vena cava has been proposed to avoid hepatic venous outflow obstruction with no theoretical concept. METHODS We herein report a standardization technique for the reconstruction of the hepatic vein based on the causal analysis. RESULTS During the put-in process, the graft must be positioned in contact with the recipient diaphragm and slightly pushed to the cranial direction to simulate the state after abdominal closure. Because there is no extra space between the graft and diaphragm, the graft could not rotate about the anastomotic site of the inferior vena cava toward the diaphragm after abdominal closure as the intestinal pressure increases, and accordingly hepatic venous outflow obstruction does not develop. CONCLUSIONS With this concept, all transplant surgeons can successfully and easily perform hepatic vein reconstruction without total clamping of the inferior vena cava and without outflow block.
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Affiliation(s)
- Kaori Kuramitsu
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan.
| | - Masahiro Kido
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Shohei Komatsu
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Daisuke Tsugawa
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Hidetoshi Gon
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Kenji Fukushima
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Takeshi Urade
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Shinichi So
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Takuya Mizumoto
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Yoshihide Nanno
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Hironori Yamashita
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Tadahiro Goto
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Hiroaki Yanagimoto
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Sadaki Asari
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Tetsuo Ajiki
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Hirochika Toyama
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
| | - Takumi Fukumoto
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Graduate School of Medicine, Kobe University, Kobe City, Hyogo, Japan
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Laroche S, Maulat C, Kitano Y, Golse N, Azoulay D, Sa Cunha A, Vibert E, Adam R, Cherqui D, Allard MA. Initial piggyback technique facilitates late liver retransplantation - a retrospective monocentric study. Transpl Int 2021; 34:835-843. [PMID: 33650170 DOI: 10.1111/tri.13857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/04/2021] [Accepted: 02/26/2021] [Indexed: 11/28/2022]
Abstract
Optimal management of inferior vena cava (IVC) is crucial to ensure safety in late liver retransplantation (ReLT). The aim of this study was to evaluate different surgical strategies with regard to IVC in late ReLT. All consecutive late ReLT (≥90 days from the previous transplant) from 2013 to 2018 in a single center was reviewed (n = 66). Of them, 46 (69.7%) were performed without venovenous bypass (VVB) including 29 with caval preservation (CP) and 17 with caval replacement (CR). The remaining 20 cases (30.3%) required the use of VVB. Among ReLT without VVB, CP was associated with a lower number of packed red blood cells (median 4 vs. 7; P = 0.016) and a lower incidence of post-transplant acute kidney injury (6.9% vs. 47.1%; P = 0.003). The feasibility of CP was 95% (14/15) in patients with previous 3-vein piggyback caval anastomosis versus 48.3% (15/31) after other techniques (P = 0.003). Indirect signs of portal hypertension (PHT) before retransplantation were predictive of VVB requirement. Early and long-term outcomes were similar across the three groups (CP without VVB, CR without VVB, and VVB). Preserving the IVC in late ReLT is associated with better postoperative renal function and is facilitated by a previous 3-vein piggyback. Routine CR is not justified in late ReLT.
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Affiliation(s)
- Sophie Laroche
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France
| | - Charlotte Maulat
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France
| | - Yuki Kitano
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Nicolas Golse
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Unité INSERM 1193, Villejuif, France
| | - Daniel Azoulay
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France
| | - Antonio Sa Cunha
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Équipe Chronothérapie, Cancers et Transplantation, Université Paris Saclay, Villejuif, France
| | - Eric Vibert
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Unité INSERM 1193, Villejuif, France
| | - René Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Équipe Chronothérapie, Cancers et Transplantation, Université Paris Saclay, Villejuif, France
| | - Daniel Cherqui
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Unité INSERM 1193, Villejuif, France
| | - Marc Antoine Allard
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Équipe Chronothérapie, Cancers et Transplantation, Université Paris Saclay, Villejuif, France
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4
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Czigany Z, Scherer MN, Pratschke J, Guba M, Nadalin S, Mehrabi A, Berlakovich G, Rogiers X, Pirenne J, Lerut J, Mathe Z, Dutkowski P, Ericzon BG, Malagó M, Heaton N, Schöning W, Bednarsch J, Neumann UP, Lurje G. Technical Aspects of Orthotopic Liver Transplantation-a Survey-Based Study Within the Eurotransplant, Swisstransplant, Scandiatransplant, and British Transplantation Society Networks. J Gastrointest Surg 2019; 23:529-537. [PMID: 30097968 DOI: 10.1007/s11605-018-3915-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 08/01/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) has emerged as the mainstay of treatment for end-stage liver disease. However, technical aspects of OLT are still subject of ongoing debate and are widely based on personal experience and local institutional protocols. METHODS An international online survey was sent out to all liver transplant centers (n = 52) within the Eurotransplant, Swisstransplant, Scandiatransplant, and British Transplant Society networks. The survey sought information on center-specific OLT caseload, vascular and biliary reconstruction, graft reperfusion, intraoperative control of hemodynamics, and drain policies. RESULTS Forty-two centers gave a valid response (81%). Out of these, 50% reported piggy-back and 40.5% total caval replacement as their standard technique. While 48% of all centers generally do not apply veno-venous bypass (vvBP) or temporary portocaval shunt (PCS) during OLT, vvBP/PCS are routinely used in six centers (14%). Portal vein first reperfusion is used in 64%, followed by simultaneous (17%), and retrograde reperfusion (12%). End-to-end duct-to-duct anastomosis without biliary drain (67%) is the most frequently performed method of biliary reconstruction. No significant associations were found between the center caseload and the surgical approach used. The predominant part of the centers (88%) stated that techniques of OLT are not evidence-based and 98% would participate in multicenter clinical trials on these topics. CONCLUSION Technical aspects of OLT vary widely among European centers. The extent to which center-specific variation of techniques affect transplant outcomes in Europe should be elucidated further in prospective multicenter trials.
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Affiliation(s)
- Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Marcus N Scherer
- Department of Surgery and Transplantation, University Hospital Regensburg, Regensburg, Germany
| | - Johann Pratschke
- Department of Surgery and Transplantation, University Hospital Berlin - Charité, Berlin, Germany
| | - Markus Guba
- Department of Surgery, University Hospital Munich, Munich, Germany
| | - Silvio Nadalin
- Department of Surgery and Transplantation, University Hospital Tuebingen, Tuebingen, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gabriela Berlakovich
- Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Xavier Rogiers
- Department of Solid Organ Transplantation, University Hospital Gent, Ghent, Belgium
| | - Jacques Pirenne
- Department of Hepatobiliary Surgery and Transplantation, University Hospital Leuven, Leuven, Belgium
| | - Jan Lerut
- Unit of Liver Transplantation and General Surgery, University Hospitals St.-Luc, Brussels, Belgium
| | - Zoltan Mathe
- Department of Surgery and Transplantation, Semmelweis University, Budapest, Hungary
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Bo-Göran Ericzon
- Department of Solid Organ Transplantation, University Hospital Stockholm - Karolinska Institute, Stockholm, Sweden
| | - Massimo Malagó
- Department of Hepatobiliary Surgery and Transplantation, University College London, London, UK
| | - Nigel Heaton
- Department of Hepatobiliary Surgery and Transplantation, King's College Hospital, London, UK
| | - Wenzel Schöning
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany.
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Doppler ultrasound in the diagnosis of Budd-Chiari syndrome in children after split liver transplantation. Diagn Interv Imaging 2018; 99:663-668. [PMID: 29853348 DOI: 10.1016/j.diii.2018.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/20/2018] [Accepted: 04/18/2018] [Indexed: 11/23/2022]
Abstract
PURPOSE To assess the capabilities of a velocity ratio>3 for the diagnosis of Budd-Chiari syndrome (BCS) in children after split liver transplantation using Doppler ultrasonography (DUS). MATERIALS AND METHODS A total of 28 children who underwent liver transplantation using a split procedure were included. There were 11boys and 17girls with a mean age of 3.8years (range: 0.7-12years). Velocity ratio between blood velocity upstream of the anastomosis and that at the level of the inferior vena cava anastomosis was calculated. Sensitivity, specificity and accuracy of DUS for the diagnosis of BCS were estimated using a velocity ratio>3. RESULTS Eight children (8/28; 29%) had BCS and 20 (20/28; 71%) did not have BCS using the standard of reference. A velocity ratio>3 on DUS yielded 88% sensitivity (95% CI: 53-98%), 80% specificity (95% CI: 58-92%) and 82% accuracy (95% CI: 64-92%) for the diagnosis of BCS. CONCLUSION A velocity ratio>3 on DUS is a reliable finding for the diagnosis of BCS in children after split liver transplantation.
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6
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Shigeta T, Sakamoto S, Sasaki K, Uchida H, Narumoto S, Fukuda A, Kasahara M. Optimizing hepatic venous outflow reconstruction for hepatic vein stenosis with indwelling stent in living donor liver retransplantation. Pediatr Transplant 2017; 21. [PMID: 28925086 DOI: 10.1111/petr.13044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 12/29/2022]
Abstract
The patient was a boy of 7 years and 5 months of age, who underwent LDLT for acute liver failure at 10 months of age. HV stent placement was performed 8 months after LDLT because of intractable HV stenosis. At 7 years of age, his liver function deteriorated due to chronic rejection. The patient therefore underwent living donor liver retransplantation from his father. The HV was transected with the stent in situ. The IVC was resected due to stenosis. The pericardial cavity was opened and detached around the IVC to elongate the IVC. The divided ends of the IVC were joined by suturing to the posterior wall of the IVC. A new triangular orifice was made by adding an incision on the anterior wall of the IVC. The graft HV was then anastomosed to the new orifice with continuous sutures in the posterior wall and interrupted sutures in the anterior wall using 5-0 non-absorbable sutures. Doppler ultrasound showed a triphasic waveform. We successfully performed HV reconstruction without a vascular graft. This is a feasible procedure for overcoming HV stenosis in LDLT patients with an indwelling stent.
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Affiliation(s)
- Takanobu Shigeta
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Kengo Sasaki
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Soichi Narumoto
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
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7
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Vetrugno L, Barbariol F, Baccarani U, Forfori F, Volpicelli G, Della Rocca G. Transesophageal echocardiography in orthotopic liver transplantation: a comprehensive intraoperative monitoring tool. Crit Ultrasound J 2017; 9:15. [PMID: 28631103 PMCID: PMC5476533 DOI: 10.1186/s13089-017-0067-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 05/31/2017] [Indexed: 01/26/2023] Open
Abstract
Intraoperative transesophageal echocardiography is a minimally invasive monitoring tool that can provide real-time visual information on ventricular function and hemodynamic volume status in patients undergoing liver transplantation. The American Association for the Study of Liver Diseases states that transesophageal echocardiography should be used in all liver transplant candidates in order to assess chamber sizes, hypertrophy, systolic and diastolic function, valvular function, and left ventricle outflow tract obstruction. However, intraoperative transesophageal echocardiography can be used to "visualize" other organs too; thanks to its proximity and access to multiple acoustic windows: liver, lung, spleen, and kidney. Although only limited scientific evidence exists promoting this comprehensive use, we describe the feasibility of TEE in the setting of liver transplantation: it is a highly valuable tool, not only as a cardiovascular monitoring, but also as a tool to evaluate lungs and pleural spaces, to assess hepatic vein blood flow and inferior vena cava anastomosis and patency, i.e., in cases of modified surgical techniques. The aim of this case series is to add our own experience of TEE as a comprehensive intraoperative monitoring tool in the field of orthotopic liver transplantation (and major liver resection) to the literature.
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Affiliation(s)
- Luigi Vetrugno
- Department of Medicine, University of Udine, P.le S. M. della Misericordia 15, 33100 Udine, Italy
| | - Federico Barbariol
- Department of Medicine, University of Udine, P.le S. M. della Misericordia 15, 33100 Udine, Italy
| | - Umberto Baccarani
- Department of Medicine, University of Udine, P.le S. M. della Misericordia 15, 33100 Udine, Italy
| | - Francesco Forfori
- Anesthesia and Intensive Care Medicine IV, Pisa University Hospital, Pisa, Italy
| | - Giovanni Volpicelli
- Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Turin, Italy
| | - Giorgio Della Rocca
- Department of Medicine, University of Udine, P.le S. M. della Misericordia 15, 33100 Udine, Italy
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8
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Ye Q, Zeng C, Wang Y, Fang Z, Hu X, Xiong Y, Li L. Risk Factors for Hepatic Venous Outflow Obstruction in Piggyback Liver Transplantation: The Role of Recipient's Pattern of Hepatic Veins Drainage into the Inferior Vena Cava. Ann Transplant 2017; 22:303-308. [PMID: 28522795 PMCID: PMC6248070 DOI: 10.12659/aot.902753] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background The recipient’s pattern of hepatic veins (HVs) drainage into the inferior vena cava (IVC) (drainage pattern, for short) may influence outflow reconstruction and thus hepatic venous outflow obstruction (HVOO) in piggyback liver transplantation (PBLT). However, no previous study has investigated this association. Material/Methods A retrospective analysis of 202 PBLT (2000–2016) was conducted. Based on drainage patterns, the patients were divided into Group A (common trunk of left and middle HVs), Group B (common trunk of right and middle HVs), and Group C (common trunk of 3 HVs). Patients’ demographic and surgical data were compared within the 3 groups, and risk factors for HVOO were tested using a multiple logistic regression model. Results A chi-square test revealed a significantly higher HVOO incidence in Group 1 compared with the other groups (23.5% vs. 9.6% vs. 7.1%, p=0.047). The demographics and surgical data except angle∠AOB between the reconstructed outflow and IVC in cross-section of 3D image (∠AOB), ratio of the length of reconstructed outflow and ∠AOB (LRO/∠AOB ratio), and types of HV ligation did not differ significantly within the 3 groups. ∠AOB and LRO/∠AOB ratio were used to assess the level of anastomosis twisting and compression, respectively. Among the 3 groups, the largest ∠AOB and highest LRO/∠AOB ratio were observed in Group A and B, respectively. In addition, multivariate analysis indicated that the ∠AOB (OR=1.016, 95%CI: 1.006–1.027) and LRO/∠AOB ratio (OR=2.254, 95% CI: 1.041–5.519) were risk factors for HVOO. Conclusions This study demonstrated that drainage patterns were associated with HVOO. The best choice for outflow reconstruction is Group C. The patients in Group A and B were likely to develop HVOO due to anastomosis twisting and compression, respectively.
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Affiliation(s)
- Qifa Ye
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland).,The 3rd Xiangya Hospital of Central South University, Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, Hunan, China (mainland)
| | - Cheng Zeng
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Yanfeng Wang
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Zhehong Fang
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Xiaoyan Hu
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Yan Xiong
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Ling Li
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
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9
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Athanasopoulos PG, Hadjittofi C, Dharmapala AD, Orti-Rodriguez RJ, Ferro A, Nasralla D, Konstantinidou SK, Malagó M. Successful Outflow Reconstruction to Salvage Traumatic Hepatic Vein-Caval Avulsion of a Normothermic Machine Ex-Situ Perfused Liver Graft: Case Report and Management of Organ Pool Challenges. Medicine (Baltimore) 2016; 95:e3119. [PMID: 27082550 PMCID: PMC4839794 DOI: 10.1097/md.0000000000003119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Donor organ shortage continues to limit the availability of liver transplantation, a successful and established therapy of end-stage liver diseases. Strategies to mitigate graft shortage include the utilization of marginal livers and recently ex-situ normothermic machine perfusion devices. A 59-year-old woman with cirrhosis due to primary sclerosing cholangitis was offered an ex-situ machine perfused graft with unnoticed severe injury of the suprahepatic vasculature due to road traffic accident. Following a complex avulsion, repair and reconstruction of all donor hepatic veins as well as the suprahepatic inferior vena cava, the patient underwent a face-to-face piggy-back orthotopic liver transplantation and was discharged on the 11th postoperative day after an uncomplicated recovery. This report illustrates the operative technique to utilize an otherwise unusable organ, in the current environment of donor shortage and declining graft quality. Normothermic machine perfusion can definitely play a role in increasing the graft pool, without compromising the quality of livers who had vascular or other damage before being ex-situ perfused. Furthermore, it emphasizes the importance of promptly and thoroughly communicating organ injuries, as well as considering all reconstructive options within the level of expertise at the recipient center.
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Affiliation(s)
- Panagiotis G Athanasopoulos
- From the Senior Clinical Fellows in Hepato-Pancreato-Biliary and Liver Transplant Surgery (PGA, ADD, RJO-R, AF), Royal Free London Hospital NHS Foundation Trust, University College London; Core Surgical Trainee (CH), Department of Oral & Maxillofacial Surgery, King's College Hospital, London; Clinical Research Fellow in Transplant Surgery (DN), Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Oxford; Department of Pharmacy & Forensic Science (SKK), King's College; and Professor of Surgery (MM), Consultant Liver Transplant and HPB Surgeon, Royal Free Hospital, Pond Street, London, UK
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10
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Fujimori M, Yamakado K, Takaki H, Nakatsuka A, Uraki J, Yamanaka T, Hasegawa T, Sugino Y, Nakajima K, Matsushita N, Mizuno S, Sakuma H, Isaji S. Long-Term Results of Stent Placement in Patients with Outflow Block After Living-Donor-Liver Transplantation. Cardiovasc Intervent Radiol 2016; 39:566-574. [PMID: 26464222 DOI: 10.1007/s00270-015-1210-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 09/12/2015] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate long-term results of stent placement retrospectively in patients with outflow block after living-donor-liver transplantation (LDLT). MATERIALS AND METHODS For this institutional review board approved retrospective study conducted during 2002-2012, stents were placed in outflow veins in 15 patients (11.3%, 15/133) (12 men; 3 female) in whom outflow block developed after LDLT. Their mean age was 52.3 years ± 15.3 (SD) (range, 4-69 years). Venous stenosis with a pressure gradient ≥5 mmHg (outflow block) was observed in the inferior vena cava in seven patients, hepatic vein in seven patients, and both in one patient. Technical success, change in a pressure gradient and clinical manifestations, and complications were evaluated. Overall survival of 15 patients undergoing outflow block stenting was compared with that of 116 patients without outflow block after LDLT. RESULTS Stents were placed across the outflow block veins without complications, lowering the pressure gradient ≤ 3 mmHg in all patients (100%, 15/15). Clinical manifestations improved in 11 patients (73.3%, 11/15), and all were discharged from the hospital. However, they did not improve in the other 4 patients (26.7%, 4/15) who died in the hospital 1.0-3.7 months after stenting (mean, 2.0 ± 1.2 months). No significant difference in 5-year survival rates was found between patients with and without outflow block after LDLT (61.1 vs. 72.2%, p = .405). CONCLUSION Stenting is a feasible, safe, and useful therapeutic option to resolve outflow block following LDLT, providing equal survival to that of patients without outflow block.
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Affiliation(s)
- Masashi Fujimori
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Koichiro Yamakado
- Department of Radiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
| | - Haruyuki Takaki
- Department of Radiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
| | - Atsuhiro Nakatsuka
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Junji Uraki
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Takashi Yamanaka
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Takaaki Hasegawa
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yuichi Sugino
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Ken Nakajima
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Naritaka Matsushita
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Shugo Mizuno
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan.
| | - Hajime Sakuma
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Shuji Isaji
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, Tsu, Mie, Japan.
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Khorsandi SE, Athale A, Vilca-Melendez H, Jassem W, Prachalias A, Srinivasan P, Rela M, Heaton N. Presentation, diagnosis, and management of early hepatic venous outflow complications in whole cadaveric liver transplant. Liver Transpl 2015; 21:914-21. [PMID: 25907399 DOI: 10.1002/lt.24154] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/30/2015] [Accepted: 04/11/2015] [Indexed: 02/07/2023]
Abstract
Early hepatic venous outflow obstruction (HVOO) can be a devastating complication leading to graft loss after liver transplantation (LT). A retrospective study on 777 adult LT recipients over a 5-year period (August 2007 to August 2012) was undertaken to determine the incidence of early HVOO presenting within 3 months of transplant, its clinical features and management, and potential technical risk factors related to the implanting technique. Cases of early HVOO were screened for by identifying recipients with problematic ascites within 3 months of transplant. Definitive diagnosis for HVOO was based on a wedge pressure of >12 mm Hg. Considering only whole livers, the incidence of early problematic ascites was 3% (20/695) of which more than one-third (35%, 7/20) were then confirmed to have HVOO. Overall, the incidence of early HVOO was 1% (7/695). Two hepatic veins (HVs) with extension piggybacks (PBs; n = 423) were the dominant implanting technique in the time period of study rather than the 3 HV PB (n = 182) and caval replacement techniques (n = 82). Considering the implantation technique, all cases of HVOO occurred after 2 HVs when extension PBs had been used with an incidence of 1.7% (7/423). Institutionally, early HVOO was mainly managed surgically by either cavoplasty within a month of transplant (n = 4) or retransplant (n = 1), and the remainder (n = 2) were medically managed with diuretics. In conclusion, early HVOO is rare, and there is no evidence from this study that a given implantation technique is at a higher risk of developing HVOO (2 HV with extension versus 3 HV and caval replacement; P = 0.11). However, early revisional surgery for HVOO can preserve graft function with retransplantation being reserved for when surgical cavoplasty or radiological stenting is technically not possible.
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Affiliation(s)
| | - Anuja Athale
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | | | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Andreas Prachalias
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Parthi Srinivasan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Mohamed Rela
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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12
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Brescia MDG, Massarollo PCB, Imakuma ES, Mies S. Prospective Randomized Trial Comparing Hepatic Venous Outflow and Renal Function after Conventional versus Piggyback Liver Transplantation. PLoS One 2015; 10:e0129923. [PMID: 26115520 PMCID: PMC4482688 DOI: 10.1371/journal.pone.0129923] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 05/11/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND This randomized prospective clinical trial compared the hepatic venous outflow drainage and renal function after conventional with venovenous bypass (n = 15) or piggyback (n = 17) liver transplantation. METHODS Free hepatic vein pressure (FHVP) and central venous pressure (CVP) measurements were performed after graft reperfusion. Postoperative serum creatinine (Cr) was measured daily on the first week and on the 14th, 21st and 28th postoperative days (PO). The prevalence of acute renal failure (ARF) up to the 28th PO was analyzed by RIFLE-AKIN criteria. A Generalized Estimating Equation (GEE) approach was used for comparison of longitudinal measurements of renal function. RESULTS FHVP-CVP gradient > 3 mm Hg was observed in 26.7% (4/15) of the patients in the conventional group and in 17.6% (3/17) in the piggyback group (p = 0.68). Median FHVP-CVP gradient was 2 mm Hg (0-8 mmHg) vs. 3 mm Hg (0-7 mm Hg) in conventional and piggyback groups, respectively (p = 0.73). There is no statistically significant difference between the conventional (1/15) and the piggyback (2/17) groups regarding massive ascites development (p = 1.00). GEE estimated marginal mean for Cr was significantly higher in conventional than in piggyback group (2.14 ± 0.26 vs. 1.47 ± 0.15 mg/dL; p = 0.02). The conventional method presented a higher prevalence of severe ARF during the first 28 PO days (OR = 3.207; 95% CI, 1.010 to 10.179; p = 0.048). CONCLUSION Patients submitted to liver transplantation using conventional or piggyback methods present similar results regarding venous outflow drainage of the graft. Conventional with venovenous bypass technique significantly increases the harm of postoperative renal dysfunction. TRIAL REGISTRATION ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT01707810.
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Affiliation(s)
- Marília D’Elboux Guimarães Brescia
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Paulo Celso Bosco Massarollo
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ernesto Sasaki Imakuma
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Sérgio Mies
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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13
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Beal EW, Bennett SC, Whitson BA, Elkhammas EA, Henry ML, Black SM. Caval reconstruction techniques in orthotopic liver transplantation. World J Surg Proced 2015; 5:41-57. [DOI: 10.5412/wjsp.v5.i1.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/28/2015] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
There are several caval reconstruction techniques currently in use for orthotopic liver transplantation. These include caval replacement or the conventional technique, performed with or without venovenous bypass, piggyback technique with anastomosis with two or three hepatic veins with or without cavotomy and modifications of the piggyback technique including end-to-side and side-to-side cavocaval anastomosis. There are few randomized controlled trials comparing the use of these techniques and our knowledge of their comparability is based on a few multi- and many single-center retrospective and prospective reviews. Although there are advantages and disadvantages for each technique, it is advisable that the surgeon perform the technique with which they have the most the experience and at which they are the most skilled as excellent outcomes can be obtained with any of the caval reconstruction options discussed.
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14
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Bypass during Liver Transplantation: Anachronism or Revival? Liver Transplantation Using a Combined Venovenous/Portal Venous Bypass-Experiences with 163 Liver Transplants in a Newly Established Liver Transplantation Program. Gastroenterol Res Pract 2015; 2015:967951. [PMID: 25821462 PMCID: PMC4363615 DOI: 10.1155/2015/967951] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/25/2015] [Accepted: 01/25/2015] [Indexed: 11/29/2022] Open
Abstract
Introduction. The venovenous/portal venous (VVP) bypass technique has generally become obsolete in liver transplantation (LT) today. We evaluated our experience with 163 consecutive LTs that used a VVP bypass. Patients and Methods. The liver transplant program was started in our center in 2010. LTs were performed using an extracorporal bypass device. Results. Mean operative time was 269 minutes and warm ischemic time 43 minutes. The median number of transfusion of packed cells and plasma was 7 and 14. There was no intraoperative death, and the 30-day mortality was 3%. Severe bypass-induced complications did not occur. Discussion. The introduction of a new LT program requires maximum safety measures for all of the parties involved. Both surgical and anaesthesiological management (reperfusion) can be controlled very reliably using a VVP bypass device. Particularly when using marginal grafts, this approach helps to minimise both surgical and anaesthesiological complications in terms of less volume overload, less use of vasopressive drugs, less myocardial injury, and better peripheral blood circulation. Conclusion. Based on our experiences while establishing a new liver transplantation program, we advocate the reappraisal of the extracorporeal VVP bypass.
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15
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Hepatic venous outflow obstruction after transplantation: Outcomes for treatment with self-expanding stents. RADIOLOGIA 2015. [DOI: 10.1016/j.rxeng.2013.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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16
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17
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Schmitz V, Schoening W, Jelkmann I, Globke B, Pascher A, Bahra M, Neuhaus P, Puhl G. Different cava reconstruction techniques in liver transplantation: piggyback versus cava resection. Hepatobiliary Pancreat Dis Int 2014; 13:242-9. [PMID: 24919606 DOI: 10.1016/s1499-3872(14)60250-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Originally, cava reconstruction (CR) in liver transplantation meant complete resection and reinsertion of the donor cava. Alternatively, preservation of the recipients inferior vena cava (IVC) with side-to-side anastomosis (known as "piggyback") can be performed. Here, partial clamping maintains blood flow of the IVC, which may improve cardiovascular stability, reduce blood loss and stabilize kidney function. The aim of this study was to compare both techniques with particular focus on kidney function. METHODS A series of 414 patients who had had adult liver transplantations (2006-2009) were included. Among them, 176 (42.5%) patients had piggyback and 238 had classical CR operation, 112 (27.1%) of the patients underwent CR accompanied with veno-venous bypass (CR-B) and 126 (30.4%) without a bypass. The choice of either technique was based on the surgeons' individual preference. Kidney function [serum creatinine, calculated glomerular filtration rate (GFR), RIFLE stages] was assessed over 14 days. RESULTS Lab-MELD scores were significantly higher in CR-B (22.5+/-11.0) than in CR (17.3+/-9.0) and piggyback (18.8+/-10.0) (P=0.008). Unexpectedly, the incidences of arterial stenoses (P=0.045) and biliary leaks (P=0.042) were significantly increased in piggyback. Preoperative serum creatinine levels were the highest in CR-B [1.45+/-1.17 vs 1.25+/-0.85 (piggyback) and 1.13+/-0.60 mg/dL (CR); P=0.033]. Although a worsening of postoperative kidney function was observed among all groups, this was most pronounced in CR-B [creatinine day 14: 1.67+/-1.40 vs 1.35+/-0.96 (piggyback) and 1.45+/-1.03 mg/dL (CR); P=0.102]. Accordingly, the proportion of patients displaying RIFLE stages ≥2 was the highest in CR/CR-B (26%/19%) when compared to piggyback (18%). CONCLUSIONS Piggyback revealed a shorter warm ischemic time, a reduced blood loss, and a decreased risk of acute kidney failure. Thus, piggyback is a useful technique, which should be applied in standard procedures. When piggyback is unfeasible, cava replacement, which displayed a lower incidence of vascular and biliary complications in our study, remains as a safe alternative.
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Affiliation(s)
- Volker Schmitz
- Department of General, Visceral and Transplantation Surgery, Charite, Campus Virchow, Berlin, Germany.
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18
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Viteri-Ramírez G, Alonso-Burgos A, Simon-Yarza I, Rotellar F, Herrero JI, Bilbao JI. Hepatic venous outflow obstruction after transplantation: outcomes for treatment with self-expanding stents. RADIOLOGIA 2014; 57:56-65. [PMID: 24784003 DOI: 10.1016/j.rx.2013.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 08/02/2013] [Accepted: 09/07/2013] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To evaluate the safety and patency of self-expanding stents to treat hepatic venous outflow obstruction after orthotopic liver transplantation. To evaluate differences in the response between patients with early obstruction and patients with late obstruction. MATERIAL AND METHODS This is a retrospective analysis of 16 patients with hepatic venous outflow obstruction after liver transplantation treated with stents (1996-2011). Follow-up included venography/manometry, ultrasonography, CT, and laboratory tests. We did a descriptive statistical analysis of the survival of patients and stents, technical and clinical success of the procedure, recurrence of obstruction, and complications of the procedure. We also did an inferential statistical analysis of the differences between patients with early and late obstruction. RESULTS The mean follow-up period was 3.34 years (21-5,331 days). The technical success rate was 93.7%, and the clinical success rate was 81.2%. The rate of complications was 25%. The survival rates were 87.5% for patients and 92.5% for stents. The rate of recurrence was 12.5%. The rate of primary patency was 0.96 (95% CI 0.91-1) at 3 months, 0.96 (95% CI 0.91-1) at 6 months, 0.87 (95% CI 0.73-1) at 12 months, and 0.87 (95% CI 0.73-1) at 60 months. There were no significant differences between patients with early and late obstruction, although there was a trend toward higher rates of primary patency in patients with early obstruction (P=.091). CONCLUSIONS Treating hepatic venous outflow obstruction after orthotopic transplantation with self-expanding stents is effective, durable, and effective. There are no significant differences between patients with early obstruction and those with late obstruction.
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Affiliation(s)
- G Viteri-Ramírez
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España.
| | - A Alonso-Burgos
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España; Servicio de Radiología, Fundación Jiménez Díaz, Madrid, España
| | - I Simon-Yarza
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España
| | - F Rotellar
- Servicio de Cirugía General y Abdominal, Clínica Universidad de Navarra, Pamplona, España
| | - J I Herrero
- Unidad de Hepatología, Clínica Universidad de Navarra, Pamplona, España
| | - J I Bilbao
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España
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19
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Ettorre GM, Santoro R, Lepiane P, Laurenzi A, Colasanti M, Meniconi RL, Colace L, Antonini M, Vennarecci G. Hanging of the hepatic veins septa: a safe control prior and during outflow anastomosis in liver transplantation. Transplant Proc 2013; 45:3314-5. [PMID: 24182808 DOI: 10.1016/j.transproceed.2013.07.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 07/09/2013] [Indexed: 11/17/2022]
Abstract
Inferior vena cava (IVC) preservation during orthotopic liver transplantation (OLT) is known as the "piggyback" technique. The end-to-side anastomosis is constructed between the graft's IVC and recipient's hepatic veins using a Satinsky side clamp applied in a transverse position. To stabilize the large Satinsky clamp and preserve a sufficient vascular stump after hepatectomy and before graft implantation, we propose a technical innovation consisting of hanging the septa between the left and middle hepatic vein and between the middle and right hepatic vein using 2 tapes. This technique showed some advantages when performing the caval outflow anastomosis, representing a further technical refinement of the piggyback end-to-side technique for the implantation on the 3 hepatic veins. From November 2001 to September 2012, we performed 272 consecutive OLT at our institution with the piggyback technique using the hanging of the hepatic veins septa in all cases. In conclusion, the hanging of the 3 hepatic veins septa presented in this study represents a simple, safe and reproducible technique for the outflow anastomosis using the piggyback technique.
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Affiliation(s)
- G M Ettorre
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital Rome, Italy.
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20
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Hwang S, Ahn CS, Kim KH, Moon DB, Ha TY, Song GW, Jung DH, Park GC, Lee SG. Liver retransplantation for adult recipients. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2013; 17:1-7. [PMID: 26155206 PMCID: PMC4304506 DOI: 10.14701/kjhbps.2013.17.1.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 02/11/2013] [Accepted: 02/16/2013] [Indexed: 01/19/2023]
Abstract
Living donor liver graft can be used for the first or second liver transplantation. The timing of retransplantation also should be stratified as 2 types according to the reoperation timing. Combination of these two classifications results in 6 types of living donor liver transplantation (LDLT)-associated retransplantation. However, late retransplantation to LDLT might have not been performed in most LDLT programs, thus other 4 types of LDLT-associated retransplantation can be taken into account. The most typical type of LDLT-associated retransplantation might be early living donor-to-deceased donor retransplantation. For early living donor-to-living donor retransplantation, its eligibility criteria might be similar to those of early living donor-to-deceased donor retransplantation. For early deceased donor-to-living donor retransplantation, its indications are exactly the same to those for aforementioned living donor-to-living donor retransplantation. Late deceased donor retransplantation after initial LDLT has the same indication for ordinary late deceased donor retransplantation.
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Affiliation(s)
- Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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21
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Pisaniello D, Marino MG, Perrella A, Russo F, Campanella L, Marcos A, Cuomo O. Side-to-side cavocavostomy in adult piggyback liver transplantation. Transplant Proc 2012; 44:1938-1941. [PMID: 22974877 DOI: 10.1016/j.transproceed.2012.06.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Our objective was to perform a retrospective study that described the anastomosis technique as well as the complications of side-to-side cavo-caval reconstruction. PATIENTS AND METHODS From June 1998 to April 2011, we performed 284 liver transplantations including 10 adults with live donor organs. In all cases but 2 (272), cavo-caval reconstruction was performed using side-to-side cavo-caval (STSCC) anastomosis. In 19 cases (6.9%), we also carried out an end-to-side temporary porto-caval shunt (TPCS). In 17 cases (6.2%) the technique was performed for retransplantation. RESULTS STSCC anastomosis was technically feasible in all but 2 cases, regardless of the recipient's vena cava, anatomic factors, or graft size. Mean operative time for the STSCC was 13 minutes (range, 6-25). Routine Doppler ultrasonography was performed intraoperatively at the end of the surgery. There was no case of cava stump thrombosis. Complications associated with this technique were limited to 2 patients. One complication was torsion due to donor graft/recipient mismatch, which was successfully treated surgically by falciform ligament fixation. The second complication was only evident by sinusoidal congestion and was managed nonoperatively. Seventeen cases were uneventful for retransplant recipients. CONCLUSIONS STSCC during piggyback liver transplantation is safe and can be performed in the retransplantation setting, with a low incidence of venous outflow obstruction that can be associated with the traditional piggyback technique. Our data suggest that donor graft to recipient mismatch is not an absolute contraindication when proper body size match is considered. A wide anastomosis with typical recipient hepatic vein inclusion is warranted with routine postanastomotic Doppler ultrasonography.
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Affiliation(s)
- D Pisaniello
- Hepatobiliary Surgery-Liver Transplant Unit, A. Cardarelli Hospital, Naples, Italy.
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Takeda K, Tanaka K, Kumamoto T, Yamada A, Yamada M, Takakura H, Kubota K, Kobayashi N, Lee J, Endo I. Severe outflow block syndrome caused by compression by the swollen caudate lobe after living donor liver transplantation: report of a case. Surg Today 2011; 42:177-80. [PMID: 22116394 DOI: 10.1007/s00595-011-0037-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Accepted: 01/21/2011] [Indexed: 12/19/2022]
Abstract
A 50-year-old man with primary biliary cirrhosis underwent living-donor liver transplantation (LDLT) using a graft of a left hemiliver with a left caudate lobe and duct-to-duct hepaticocholedochostomy. Postoperative bile leakage necessitated percutaneous drainage 22 days after LDLT. The patient presented to our hospital 205 days after the LDLT with abdominal distension and fever. Computed tomography showed ascites and a diffusely mottled pattern in the graft. The caudate lobe was swollen, and its bile ducts were dilated. The inferior vena cava was forced to the right by the swollen caudate lobe, and the root of the hepatic vein was stretched. The hepatic vein was not contrasted. Endoscopic retrograde cholangiography showed a biliary anastomotic stricture. Based on these findings, we diagnosed a severe outflow block of the hepatic vein and biliary anastomotic stricture. We performed balloon dilation of the biliary anastomosis and implanted a metallic stent in the hepatic vein. Thereafter, his clinical symptoms improved dramatically.
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Affiliation(s)
- Kazuhisa Takeda
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.
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Kim IG, Kim BS, Jeon JY, Kwon JW, Kim JS, Kim DJ, Jung JP, Chon SE, Kim HJ, Jeon EY, Kim MJ, Lee K. Cavo-caval intervention stent insertion after deceased-donor liver transplantation using side-to-side piggyback technique: report of a case. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2011; 15:184-8. [PMID: 26421037 PMCID: PMC4582544 DOI: 10.14701/kjhbps.2011.15.3.184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Revised: 08/04/2011] [Accepted: 08/14/2011] [Indexed: 11/17/2022]
Abstract
Liver transplantation with preservation of the recipient vena cava (piggyback technique) has been performed as an alternative to the conventional method. Outflow disturbance or obstruction of the vena cava in the early period after liver transplantation is associated with high morbidity and mortality. We used side-to-side cavo-caval anastomosis (modified piggyback technique) in a deceased-donor liver transplantation (DDLT) for venous outflow reconstruction. On postoperative day 9, the patient developed abdominal discomfort, and abnormal liver function showing serum total bilirubin of 6.2 mg/dl and serum AST/ALT of 297/597 IU/L. Doppler ultrasound showed mono-phasic wave forms of the hepatic vein. Computed tomography showed focal narrowing of 9.5 mm×12 mm in diameter at the cavo-caval anastomosis site. Liver biopsy was showed that there was no evidence of acute allograft rejection. Direct venogram showed stenosis of the cavo-caval anastomosis with a pressure gradient of 12 mmHg. An interventional stent was inserted in the stenotic site of the inferior vena cava, and the pressure gradient decreased to 2 mmHg. He was discharged from hospital on postoperative day 23 without any other complications. Herein we report a case of deceased-donor liver transplantation using the modified piggyback technique, who received an inferior vena cava stent due to stricture of the reconstructed orifice of the vena cava.
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Affiliation(s)
- In-Gyu Kim
- Department of Surgery, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Byung Seup Kim
- Department of Surgery, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Jang Yong Jeon
- Department of Surgery, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Jae Woo Kwon
- Department of Surgery, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Joo Seop Kim
- Department of Surgery, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Doo Jin Kim
- Department of Surgery, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Jae Pil Jung
- Department of Surgery, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Seong Eun Chon
- Department of Surgery, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Han Joon Kim
- Department of Surgery, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Eui Yong Jeon
- Department of Radiology, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Min-Jeong Kim
- Department of Radiology, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Kwanseop Lee
- Department of Radiology, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
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Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna. Ann Surg 2011; 253:378-84. [PMID: 21183851 DOI: 10.1097/sla.0b013e318206818b] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the evolution of liver transplantation (LT) in cases with partial and total portal vein thrombosis (PVT). BACKGROUND Portal vein thrombosis and in particular total PVT are still surgically demanding conditions, which can exclude patients from LT or increase the postoperative complications after LT. METHODS We reviewed our 10-year experience (first era 1998–2002 and second era 2003–2008), comparing the outcome of patients with PVT to a group without PVT. RESULTS Among 889 LTs, we intraoperatively diagnosed 91 PVTs (10.2%):51 partial PVTs (56%) and 40 total PVTs (44%). The rate of complete PVTs increased from the first to the second era (2.2% vs. 6.7%, P < 0.005). Partial PVTs were mainly treated with thrombectomy while complete PVTs were managed with thrombectomy in 26 cases (63%), jumping graft in 6 (15%), portocaval hemitransposition in 6 (15%), and anastomosis to varix in 3 (7%). Among cases of PVT and no-PVT, the postoperative mortality was comparable (6.6% vs. 5.8%), as were the 1- and 5-year patient survival rates (85% and 68% PVT vs. 86% and 73% non-PVT). The postoperative outcome was similar in the PVT group between patients with partial and complete PVT, but in this last group, patient survival differed significantly between the 1st and 2nd era (57% vs. 89% at 1 year, P < 0.05). CONCLUSIONS Liver transplantation offers good survival in patients with partial PVT but also in selected cases with total PVT, where surgical innovation has improved the results.
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Wojcicki M, Post M, Pakosz-Golanowska M, Zeair S, Lubikowski J, Jarosz K, Czuprynska M, Milkiewicz P. Vascular complications following adult piggyback liver transplantation with end-to-side cavo-cavostomy: a single-center experience. Transplant Proc 2010; 41:3131-4. [PMID: 19857694 DOI: 10.1016/j.transproceed.2009.07.092] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Vascular complications remain a significant cause of morbidity, graft loss, and mortality following orthotopic liver transplantation (OLT). These problems predominantly include hepatic artery and portal vein thrombosis or stenosis. Venous outflow obstruction may be specifically related to the technique of piggyback OLT. MATERIALS AND METHODS Between February 2002 and February 2009, we performed 200 piggyback OLT in 190 recipients. A temporary portacaval shunt was created in 44 (22%) cases, whereas end-to-side cavo-cavostomy was routinely performed for graft implantation. Pre-existent partial portal or superior mesenteric vein thrombosis was present in 17 (12%) cirrhotics in whom we successfully performed eversion thrombectomy, which was followed by a typical end-to-end portal anastomosis. The donor hepatic artery was anastomosed to the recipient aorta via an iliac interposition graft in 31 (16%) patients. RESULTS The 14 (7%) vascular complications included hepatic artery thrombosis (n = 5), hepatic artery stenosis (n = 3), aortic/celiac trunk rupture (n = 2), portal vein stenosis (n = 2), and isolated left and middle hepatic venous outflow obstruction (n = 1). There was also 1 case of arterial steal syndrome via the splenic artery. No patient experienced portal or mesenteric vein thrombosis. Therapeutic modalities included re-OLT, arterial/aortic reconstruction and splenic artery ligation. Vascular complications resulted in death of 5 (36%) patients. CONCLUSION Our experience indicated that piggyback OLT with an end-to-side cavo-cavostomy showed a low risk of venous outflow obstruction. Partial portal or mesenteric vein thrombosis is no longer an obstacle to OLT; it can be successfully managed with the eversion thrombectomy technique.
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Affiliation(s)
- M Wojcicki
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Marie Curie Hospital, ul. Arkonska 4; 71-455 Szczecin, Poland.
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Audet M, Piardi T, Panaro F, Cag M, Habibeh H, Gheza F, Portolani N, Cinqualbre J, Jaeck D, Wolf P. Four hundred and twenty-three consecutive adults piggy-back liver transplantations with the three suprahepatic veins: was the portal systemic shunt required? J Gastroenterol Hepatol 2010; 25:591-596. [PMID: 19968745 DOI: 10.1111/j.1440-1746.2009.06084.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The aim of this study is to analyze a single-center experience in orthotopic liver transplantation with the piggy-back technique (PB) realized with a cuff of three veins without temporary portacaval shunt. Outcome parameters were graft and patient survival and the surgical complications. METHODS The records of 423 liver transplantation in 396 adult recipients were reviewed. PB was performed in all cases also in patients with transjugular intrahepatic portosystemic shunts and redo transplants without temporary portacaval shunt. No hemodynamic instability was observed during venous reconstruction. RESULTS Operation time, cold ischemia time and anhepatic phase were, respectively, 316, 606 and 82 min, respectively. The mean intraoperative transfusion of packed red blood cells was 3.2 (range 1-48). Surgical complications were observed in 25% of the orthotopic liver transplantation and 2% of these was related to caval anastomosis. No case of caval thrombosis was observed; a stenosis was noted in seven patients, always treated with an endovascular approach. A postoperative ascites was observed in seven cases. Retransplantation was required in 6.3% patients. Overall in-hospital mortality was 5.3%, but no patient died through technical problems or complications related to PB procedure. One-, 3- and 5-year grafts and patients were 94%, 83% and 75%, and 92%, 86% and 79%, respectively. CONCLUSION This experience indicates that our approach is feasible with a low specific risk and can be performed without portacaval shunt, with minimal outflow venous complications.
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Affiliation(s)
- Maxime Audet
- Department of Surgery, Multivisceral Transplant Centre, Hopital Hautepierre, University of Strasbourg, Strasbourg, France
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Ravaioli M, Cescon M, Grazi GL, Ercolani G, Del Gaudio M, Cucchetti A, Vivarelli M, Di Gioia P, Vetrone G, Pinna AD. Liver transplantation with left lateral segments in adults: a risk or a possibility? Transplantation 2009; 88:849-850. [PMID: 19920788 DOI: 10.1097/tp.0b013e3181b4e8c3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Polak WG, Peeters PM, Slooff MJ. The evolution of surgical techniques in clinical liver transplantation. A review. Clin Transplant 2009; 23:546-64. [DOI: 10.1111/j.1399-0012.2009.00994.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Mehrabi A, Mood ZA, Fonouni H, Kashfi A, Hillebrand N, Müller SA, Encke J, Büchler MW, Schmidt J. A single-center experience of 500 liver transplants using the modified piggyback technique by Belghiti. Liver Transpl 2009; 15:466-74. [PMID: 19399735 DOI: 10.1002/lt.21705] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Over the past 4 decades, the surgical techniques of liver transplantation (LTx) have permanently evolved and been modified. Among these, the modified piggyback (MPB) technique by Belghiti offers specific advantages. The objective of this study was to present our single-center experience with the MPB technique in 500 cases. Recipients' perioperative data were prospectively collected and evaluated. Postoperative and specific complications, stay in the intensive and intermediate care unit, and the mortality rate with cause of death were analyzed. Most recipients were classified as Child C (49.1%). For the patients who underwent LTx for the first time, alcoholic (23.9%) and viral (22.2%) cirrhosis and hepatocellular carcinoma (15.1%) were the prevalent indications. The overall median warm ischemia time, anastomosis duration, and operative time were 45, 108, and 320 minutes, respectively. The median intraoperative blood loss was 1500 mL. A venovenous bypass was never needed to maintain hemodynamic stability. Only in a few cases was temporary inferior vena cava clamping necessary. Most prominent surgical complications were hemorrhage, hematoma, and wound dehiscence. Renal failure occurred in 6.2% of patients. The overall median stay in the intensive and intermediate care unit was 14 days. The mortality rates within 30 and 90 days were 6.3% and 13.3%, respectively. No technique-related death occurred. The MPB technique by Belghiti is a feasible and simple LTx technique. The caval flow is preserved during the anhepatic phase, and this minimizes the need for venovenous bypass or portocaval shunt. This technique requires only 1 caval anastomosis, which is easy to perform with a short anhepatic phase. To minimize the risk of outflow obstruction, attention should be paid by doing a wide cavocavostomy cranially to the donor inferior vena cava in a door-lock manner. This technique can be applied in almost all patients undergoing LTx for the first time and liver retransplantation as well.
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Affiliation(s)
- Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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30
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Chong WK, Beland JC, Weeks SM. Sonographic evaluation of venous obstruction in liver transplants. AJR Am J Roentgenol 2007; 188:W515-21. [PMID: 17515341 DOI: 10.2214/ajr.06.1262] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of our study was to identify specific Doppler criteria for portal vein and outflow vein (hepatic veins and inferior vena cava) obstruction in liver transplants. MATERIALS AND METHODS A retrospective review was performed of Doppler sonographic studies and angiograms in 94 liver transplant cases (72 whole liver, 22 lobar) with suspected vascular obstruction. The angiograms were classified as normal, occluded, or stenosed on the basis of appearance and elevated pressure gradient. Sonography was correlated with angiography. The following Doppler parameters were evaluated: for the portal vein, peak anastomotic velocity and anastomotic-to-preanastomotic velocity ratio; and for the outflow veins, venous pulsatility index. Receiver operating characteristic curves were constructed and optimum thresholds for stenosis were defined. RESULTS There were 16 cases of portal vein obstruction (11 stenosis, five occlusion) and 35 cases of outflow vein obstruction (34 stenoses, one occlusion). Mean peak anastomotic velocity in normal portal veins was 58 cm/s, whereas mean peak anastomotic velocity in stenosed veins was 155 cm/s (p = 0.0007). Peak anastomotic velocity threshold of > 125 cm/s was 73% sensitive and 95% specific for stenosis. Mean anastomotic-to-preanastomotic velocity ratio in normal portal veins was 1.5, and mean anastomotic-to-preanastomotic velocity ratio in stenosed veins was 4.69 (p = 0.001). A 3:1 ratio was 73% sensitive and 100% specific for stenosis. Mean venous pulsatility index for normal outflow veins was 0.75, and mean venous pulsatility index in stenosed veins was 0.39. A venous pulsatility index of < 0.45 was 95.7% specific for stenosis. The areas under the receiver operating characteristic curve were 0.83 for peak anastomotic velocity, 0.86 for anastomotic-to-preanastomotic velocity ratio, and 0.84 for venous pulsatility index, indicating good correlation. CONCLUSION Peak anastomotic velocity, anastomotic-to-preanastomotic velocity ratio, and venous pulsatility index are useful parameters for diagnosing venous stenosis in liver transplants.
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Affiliation(s)
- Wui K Chong
- Department of Radiology, CB 7510, University of North Carolina Hospitals, 101 Manning Dr., Chapel Hill, NC 27599-7510, USA
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31
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Affiliation(s)
- James D Perkins
- Department of Surgery, Divsion of Transplantation, University of Washington Medical Center, Seattle, WA, USA
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Polak WG, Nemes BA, Miyamoto S, Peeters PMJG, de Jong KP, Porte RJ, Slooff MJH. End-to-side caval anastomosis in adult piggyback liver transplantation. Clin Transplant 2007; 20:609-16. [PMID: 16968487 DOI: 10.1111/j.1399-0012.2006.00525.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
No consensus exists regarding the optimal reconstruction of the cavo-caval anastomosis in piggyback orthotopic liver transplantation (PB-LT). The aim of this study was to analyze our experience with end-to-side (ES) cavo-cavostomy. Outcome parameters were patient and graft survival and surgical complications. During the period 1995-2002 146 full-size PB-LT in 137 adult patients were performed with ES cavo-cavostomy without the routine use of temporary portocaval shunt (TPCS). In 12 patients (8%) this technique was used for implantation of second or third grafts. Veno-venous bypass was not used in any case and TPCS was performed only in eight patients (6%). One-, three- and five-yr patient and graft survival were 84%, 79% and 75%, and 81%, 74% and 69%, respectively. The median number of intraoperative transfusion of packed red blood cells (RBC) was 2.0 (range 0-33) and 30% of the patients (n = 43) did not require any RBC transfusion. Surgical complications of various types were observed after 49 LT (34%) and none of the complications was specifically related to the technique of ES cavo-cavostomy. Our experience indicates that PB-LT with ES cavo-cavostomy is a safe procedure, can safely be performed without the routine use of a TPCS, has a very low risk of venous outflow obstruction and can also be used effectively during retransplantations.
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Affiliation(s)
- Wojciech G Polak
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Khan S, Silva MA, Tan YM, John A, Gunson B, Buckels JAC, David Mayer A, Bramhall SR, Mirza DF. Conventional versus piggyback technique of caval implantation; without extra-corporeal veno-venous bypass. A comparative study. Transpl Int 2007; 19:795-801. [PMID: 16961770 DOI: 10.1111/j.1432-2277.2006.00331.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Conventional orthotopic liver transplantation (CON-LT) involves resection of recipient cava, usually with extra-corporeal circulation (veno-venous bypass, VVB), while in the piggyback technique (PC-LT) the cava is preserved. Along with a temporary portacaval shunt (TPCS), better haemodynamic maintenance is purported with PC-LT. A prospective, consecutive series of 384 primary transplants (2000-2003) were analysed, 138 CON-LT (with VVB) and 246 PC-LT (54 without TPCS). Patient/donor characteristics were similar in the two groups. PC-LT required less usage of fresh-frozen plasma and platelets, intensive care stay, number of patients requiring ventilation after day 1 and total days spent on ventilator. The results were not different when comparing, total operating and warm ischaemia time (WIT), red cell usage, requirement for renal support, day 3 serum creatinine and total hospital stay. TPCS had no impact on outcome other than WIT (P = 0.02). Three patients in PC-LT group (three of 246;1.2%) developed caval outflow obstruction (P = 0.02). There was no difference in short- or long-term graft or patient survival. PC-LT has an advantage over CON-LT unsing VVB with respect to intraoperative blood product usage, postoperative ventilation requirement and ITU stay. VVB is no longer required and TPCS may be used selectively in adult transplantation.
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Affiliation(s)
- Saboor Khan
- Liver Unit (Liver Transplantation and Hepatobiliary Surgery), University Hospital Birmingham NHS Trust, Queen Elizabeth, Edgbaston, Birmingham, UK
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Aucejo F, Winans C, Henderson JM, Vogt D, Eghtesad B, Fung JJ, Sands M, Miller CM. Isolated right hepatic vein obstruction after piggyback liver transplantation. Liver Transpl 2006; 12:808-12. [PMID: 16628691 DOI: 10.1002/lt.20747] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The "piggyback" technique for liver transplantation has gained worldwide acceptance. Still, complications such as outflow obstruction have been observed, usually attributable to technical errors such as small-caliber anastomosis of the suprahepatic vena cava, twisting, or kinking. Iatrogenic Budd-Chiari syndrome after piggyback liver transplantation has been reported as a consequence of obstruction involving the entire anastomosis (usually the 3 hepatic veins). Here we describe technical issues, clinical presentation, diagnosis, and treatment of 3 cases in which outflow obstruction affected only the right hepatic vein. In conclusion, all 3 patients developed recurrent ascites requiring angioplasty and/or stent placement across the right hepatic vein to alleviate the symptoms.
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Affiliation(s)
- Federico Aucejo
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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