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Toshima T, Itoh S, Morita K, Nagao Y, Kurihara T, Tomino T, Kosai-Fujimoto Y, Tomiyama T, Toshida K, Harada N, Yoshizumi T. Feasibility of venous cuff using an open round ligament or inferior mesenteric vein around the hepatic vein for a left lobe graft in living-donor liver transplantation. Surg Today 2024; 54:812-816. [PMID: 38170224 DOI: 10.1007/s00595-023-02791-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 11/09/2023] [Indexed: 01/05/2024]
Abstract
Living-donor liver transplantation (LDLT) is an established treatment for patients with end-stage liver disease or acute liver failure, and outflow reconstruction is considered one of the most vital techniques in LDLT. To date, many strategies have been reported to prevent outflow obstruction, which can be refractory to liver dysfunction and can cause life-threatening graft loss or mortality. In addition, in this era of laparoscopic hepatectomy in donor surgery, especially LDLT using a left liver graft, it has been predicted that cutting the hepatic vein with automatic linear staplers will lead to more outflow-related problems than with conventional open hepatectomy because of the short neck of the anastomosis orifice. We herein review 10 cases of venoplasty performed with a novel venous cuff system using a donor's round ligament around the hepatic vein in LDLT with a left lobe graft, which makes anastomosis of the hepatic vein sterically easy for postoperative venous patency.
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Affiliation(s)
- Takeo Toshima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
- Department of Surgery, Kyushu University Beppu Hospital, Oita, Japan.
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Kazutoyo Morita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yoshihiro Nagao
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Takeshi Kurihara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Takahiro Tomino
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yukiko Kosai-Fujimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Takahiro Tomiyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Katsuya Toshida
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Noboru Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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Schullian P, Johnston E, Laimer G, Scharll Y, Putzer D, Eberle G, Kolbitsch C, Amann A, Stättner S, Bale R. Stereotactic radiofrequency ablation of tumors at the hepatic venous confluence. HPB (Oxford) 2022; 24:1044-1054. [PMID: 34887174 DOI: 10.1016/j.hpb.2021.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/30/2021] [Accepted: 11/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Radiofrequency ablation (RFA) is subject to "heat-sink" effects, particularly for treatment of tumors adjacent to major vessels. METHODS In this retrospective study, 104 patients with 137 tumors (40 HCC, 10 ICC and 54 metastatic liver tumors) close to (≤1 cm from) the hepatic venous confluence underwent stereotactic RFA (SRFA) between June 2003 and June 2018. Median tumor size was 3.7 cm (1.4-8.5) for HCC, 6.4 cm (0.5-11) for ICC and 3.8 cm (0.5-13) for metastases. Endpoints comprised safety, local tumor control, overall and disease-free survival. RESULTS The overall major complication rate was 16.0% (20/125 ablations), where 8 (40%) were successfully treated by the interventional radiologist in the same anesthetic session and did not prolong hospital stay. 134/137 (97.8%) tumors were successfully ablated at initial SRFA. Local recurrence (LR) developed in 19/137 tumors (13.9%). The median and overall survival (OS) rates at 1-, 3-, and 5- years from the date of the first SRFA were 51.5 months, 73.5%, 67.0%, and 49.7% for HCC, 14.6 months, 60.0%, 32.0% and 32.0% for ICC and 38.1 months, 91.4%, 56.5% and 27.9% for metastatic disease, respectively. CONCLUSION SRFA represents a viable alternative to hepatic resection for challenging tumors at the hepatic venous confluence.
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Affiliation(s)
- Peter Schullian
- Department of Radiology, Section of Interventional Oncology - Microinvasive Therapy (SIP), Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Edward Johnston
- Department of Radiology, The Royal Marsden Hospital, 203 Fulham Road, Chelsea, London, SW3 6JJ, UK
| | - Gregor Laimer
- Department of Radiology, Section of Interventional Oncology - Microinvasive Therapy (SIP), Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Yannick Scharll
- Department of Radiology, Section of Interventional Oncology - Microinvasive Therapy (SIP), Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Daniel Putzer
- Department of Radiology, Section of Interventional Oncology - Microinvasive Therapy (SIP), Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Gernot Eberle
- Department of Radiology, Section of Interventional Oncology - Microinvasive Therapy (SIP), Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Christian Kolbitsch
- Department of Anesthesia, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Arno Amann
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck Austria
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergut Klinikum, D.Wilhelm Bock Strasse 1, 4840, Vöcklabruck Austria; Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Reto Bale
- Department of Radiology, Section of Interventional Oncology - Microinvasive Therapy (SIP), Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria.
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Jiang T, Ran B, Guo Q, Zhang R, Duan S, Zhong K, Wen H, Shao Y, Aji T. Use of the ligamentum teres hepatis for outflow reconstruction during ex vivo liver resection and autotransplantation in patients with hepatic alveolar echinococcosis: A case series of 24 patients. Surgery 2021; 170:822-830. [PMID: 33994007 DOI: 10.1016/j.surg.2021.03.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/03/2021] [Accepted: 03/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with extensive hepatic alveolar echinococcosis might require ex vivo liver resection and autotransplantation to remove the lesion. Patients with extensive vascular invasion will need reconstruction, but the selection of the proper graft is complicated. This study aimed to investigate the effectiveness and adverse events of using the ligamentum teres hepatis as a vascular replacement graft in ex vivo liver resection and autotransplantation. METHODS This was a retrospective case series of patients with hepatic alveolar echinococcosis who underwent ex vivo liver resection and autotransplantation between August 2010 and October 2018 and in whom the ligamentum teres hepatis was used to repair the remnant liver. The operative outcomes, recurrence, and survival were examined. RESULTS Twenty-four patients were included (10 men, 14 women). The anhepatic period was 290 to 672 minutes (median of 450 minutes). The ratio of the remnant liver volume to the standard liver volume was 0.43 to 0.97 (median of 0.71). The blood loss was 1,000 (500-5,000) mL. The postoperative hospital stay was 23 (1-85) days. Of the 24 patients, 3 died after the operation, but those deaths were unrelated to liver vascular complications. CONCLUSION The ligamentum teres hepatis could be used as a vascular replacement graft in ex vivo liver resection and autotransplantation. It has the advantages of convenient specimen extraction, no donor site injury, and no immunological rejection, which has promising clinical application prospects.
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Affiliation(s)
- Tiemin Jiang
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Bo Ran
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Qiang Guo
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Ruiqing Zhang
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Shuai Duan
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Kai Zhong
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Hao Wen
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yingmei Shao
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Tuerganaili Aji
- State Key Laboratory of Pathogenesis, Prevention, and Management of High Incidence Diseases in Central Asia, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Department of Hepatobiliary and Echinococcosis Surgery, Digestive and Vascular Surgery Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Xinjiang Uyghur Autonomous Region Key Laboratory of Echinococcosis, Clinical Medical Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
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Ikegami T, Onda S, Furukawa K, Haruki K, Shirai Y, Gocho T. Small-for-size graft, small-for-size syndrome and inflow modulation in living donor liver transplantation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:799-809. [PMID: 32897590 DOI: 10.1002/jhbp.822] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/18/2020] [Accepted: 08/18/2020] [Indexed: 01/10/2023]
Abstract
The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called "small-for-size syndrome (SFSS)." The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extending to include a right lobe graft. Clinical cases of living right lobe donations have been reported since then, drawing attention to the risks of increasing the liver volume procured from a living donor. However, not only other modes of increasing graft volume (GV) such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by a small-for-size graft (SFSG), such as a porto-systemic shunt or splenectomy and optimal outflow reconstruction, have been trialed with some positive results. To establish an effective strategy for transplanting SFSG and preventing SFSS, it is essential to have precise knowledge and tactics to evaluate graft quality and GV, when performing these LDLTs with portal pressure control and good venous outflow. Thus, we reviewed the updated literature on the pathogenesis of and strategies for using SFSG.
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Affiliation(s)
- Toru Ikegami
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiro Shirai
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Gocho
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Toshima T, Yoshizumi T, Shimokawa M, Ikegami T, Harada N, Itoh S, Mano Y, Motomura T, Soejima Y, Maehara Y. Feasibility of All-in-One Venoplasty With a Venous Cuff Using an Opened Round Ligament for the Right Lobe Graft in Living Donor Liver Transplantation. Liver Transpl 2019; 25:171-175. [PMID: 30230163 DOI: 10.1002/lt.25339] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 09/06/2018] [Indexed: 12/09/2022]
Affiliation(s)
- Takeo Toshima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Shimokawa
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noboru Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yohei Mano
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takashi Motomura
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuji Soejima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Linares I, Goldaracena N, Rosales R, Maza LDL, Kaths M, Kollmann D, Echeverri J, Selzner N, McCluskey SA, Sapisochin G, Lilly LB, Greig P, Bhat M, Ghanekar A, Cattral M, McGilvray I, Grant D, Selzner M. Splenectomy as Flow Modulation Strategy and Risk Factors of De Novo Portal Vein Thrombosis in Adult-to-Adult Living Donor Liver Transplantation. Liver Transpl 2018; 24:1209-1220. [PMID: 30146768 DOI: 10.1002/lt.25212] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/14/2018] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT) is a severe complication after liver transplantation that can result in increased morbidity and mortality. Few data are available regarding risk factors, classification, and treatment of PVT after living donor liver transplantation (LDLT). Between January 2004 and November 2014, 421 adult-to-adult LDLTs were performed at our institution, and they were included in the analysis. Perioperative characteristics and outcomes from patients with no-PVT (n = 393) were compared with those with de novo PVT (total portal vein thrombosis [t-PVT]; n = 28). Ten patients had early portal vein thrombosis (e-PVT) occurring within 1 month, and 18 patients had late portal vein thrombosis (l-PVT) appearing later than 1 month after LDLT. Analysis of perioperative variables determined that splenectomy was associated with t-PVT (hazard ratio [HR], 3.55; P = 0.01), e-PVT (HR, 4.96; P = 0.04), and l-PVT (HR, 3.84; P = 0.03). In contrast, donor age was only found as a risk factor for l-PVT (HR, 1.05; P = 0.01). Salvage rate for treatment in e-PVT and l-PVT was 100% and 50%, respectively, without having an early event of rethrombosis. Mortality within 30 days did not show a significant difference between groups (no-PVT, 2% versus e-PVT, 10%; P = 0.15). No significant differences were found regarding 1-year (89% versus 92%), 5-year (79% versus 82%), and 10-year (69% versus 79%) graft survival between the t-PVT and no-PVT groups, respectively (P = 0.24). The 1-year (89% versus 96%), 5-year (82% versus 86%), and 10-year (79% versus 83%) patient survival was similar for the patients in the no-PVT and t-PVT groups, respectively (P = 0.70). No cases of graft loss occurred as a direct consequence of PVT. In conclusion, the early diagnosis and management of PVT after LDLT can lead to acceptable early and longterm results without affecting patient and graft survival.
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Affiliation(s)
- Ivan Linares
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Roizar Rosales
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Luis De la Maza
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Moritz Kaths
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Dagmar Kollmann
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Juan Echeverri
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Nazia Selzner
- Department of Medicine, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Stuart A McCluskey
- Department of Anesthesiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Leslie B Lilly
- Department of Medicine, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Paul Greig
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Department of Medicine, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mark Cattral
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ian McGilvray
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - David Grant
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Markus Selzner
- Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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Lee TB, Choi BH, Yang KH, Ryu JH, Park YM, Chu CW. Diamond-shaped patch technique for right hepatic vein reconstruction in living-donor liver transplant: A simple method to prevent stenosis. Medicine (Baltimore) 2018; 97:e11815. [PMID: 30142770 PMCID: PMC6112875 DOI: 10.1097/md.0000000000011815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patency of the right hepatic vein (RHV) of the liver graft is essential for successful living-donor liver transplant (LDLT). We developed a simple technique for RHV reconstruction that does not require the use of cadaveric veins or additional time to prevent stenosis.Of 159 patients who underwent LDLT at our institution between May 2010 and April 2016, we included 152 in this study. Conventional RHV reconstruction was performed in 100 patients, while the diamond-shaped patch (D-patch) technique was performed in 53. For the D-patch technique, the posterior aspect of the RHV needs to be dissected from the liver parenchyma during donor hepatectomy, which prevents stenosis due to liver rotation after graft regeneration. A D-patch obtained from the hepatic vein of the recipient liver was used on the anterior aspect of the RHV for reconstruction. The Student's t test and χ test were used for statistical analysis.Rates of intervention for RHV stenosis during the first month were significantly different between the conventional reconstruction and D-patch groups (19.2% vs 3.8%; P = .01). The time taken to perform the D-patch technique was similar to that for conventional reconstruction (anhepatic period, 104.9 ± 47.3 minutes vs 106.7 ± 42.0 minutes; P = .82).The D-patch technique for RHV reconstruction in LDLT is a simple, fast, and feasible surgical technique that can be performed without using cadaveric or saphenous veins.
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Affiliation(s)
- Tae Beom Lee
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Byung Hyun Choi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Kwang Ho Yang
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Je Ho Ryu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Pusan National University Yangsan Hospital
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Young Mok Park
- Department of Organ Transplantation Center, Vinmec Hospital, Hanoi, Time City, Vietnam
| | - Chong Woo Chu
- Department of Organ Transplantation Center, Vinmec Hospital, Hanoi, Time City, Vietnam
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8
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Soejima Y, Yoshizumi T, Ikegami T, Harimoto N, Harada N, Ito S, Motomura T, Uchiyama H, Maehara Y. In Situ Procurement of a Recipient's Portal Vein for a Right Lobe Liver Graft With Multiple Venous Orifices: A Case Report. Transplant Proc 2017; 49:172-174. [PMID: 28104129 DOI: 10.1016/j.transproceed.2016.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 09/27/2016] [Accepted: 10/27/2016] [Indexed: 11/28/2022]
Abstract
Reconstruction of multiple venous orifices of a right lobe graft is a time-consuming and troublesome procedure in right lobe living-donor liver transplantation. In the current study, we present a new venous reconstruction technique for a right lobe graft with multiple and complex hepatic vein (HV) orifices, in which procurement of the recipient's left portal vein was performed in situ to keep the anhepatic period to a minimum. All of the HV orifices were reconstructed together at the back table, while maintaining patency of the recipient's systemic and splanchnic circulation. A homologous vein graft and veno-venous bypass were not necessary. All HVs were patent during the follow-up and the patient was free from complications. In conclusion, the present technique is readily available for reconstruction of complex and multiple HV tributaries, while avoiding a long anhepatic time and the use of veno-venous bypass.
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Affiliation(s)
- Y Soejima
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan.
| | - T Yoshizumi
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - T Ikegami
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - N Harimoto
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - N Harada
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - S Ito
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - T Motomura
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - H Uchiyama
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - Y Maehara
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
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9
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Shimagaki T, Yoshizumi T, Itoh S, Motomura T, Nagatsu A, Harada N, Harimoto N, Ikegami T, Soejima Y, Maehara Y. Liver resection with right hepatic vein reconstruction using the internal jugular vein: a case report. Surg Case Rep 2016; 2:132. [PMID: 27838914 PMCID: PMC5107183 DOI: 10.1186/s40792-016-0258-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/08/2016] [Indexed: 11/16/2022] Open
Abstract
Background The role of hepatectomy for malignant liver tumors has expanded during the past decades, and vascular reconstruction during liver resection is sometimes necessary to achieve curative surgery. Case presentation We report a case of liver resection in a 54-year-old male who had liver metastasis that invaded the right hepatic vein. He had undergone laparoscopic low anterior resection for rectal cancer. Six months later, liver metastasis was detected. After the reduction of the tumor by preoperative chemotherapy, liver resection with right hepatic vein reconstruction using his own internal jugular vein graft was performed. The postoperative course was uneventful, and the patient was discharged 8 days after the surgery. Conclusions Internal jugular vein grafts are superior to other types of vascular grafts for vascular reconstruction in liver surgery.
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Affiliation(s)
- Tomonari Shimagaki
- Department of Surgery and Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Shinji Itoh
- Department of Surgery and Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takashi Motomura
- Department of Surgery and Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Akihisa Nagatsu
- Department of Surgery and Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Noboru Harada
- Department of Surgery and Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Norifumi Harimoto
- Department of Surgery and Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Toru Ikegami
- Department of Surgery and Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yuji Soejima
- Department of Surgery and Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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10
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Sanada Y, Sakuma Y, Sasanuma H, Miki A, Katano T, Hirata Y, Okada N, Yamada N, Ihara Y, Urahashi T, Sata N, Yasuda Y, Mizuta K. Immunohistochemical evaluation for outflow reconstruction using opened round ligament in living donor right posterior sector graft liver transplantation: A case report. World J Gastroenterol 2016; 22:7851-7856. [PMID: 27678368 PMCID: PMC5016385 DOI: 10.3748/wjg.v22.i34.7851] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 06/11/2016] [Accepted: 07/06/2016] [Indexed: 02/06/2023] Open
Abstract
Utilizing the opened round ligament as venous grafts during liver transplantation is useful but controversial, and there are no pathological analyses of this procedure. Herein, we describe the first reported case of a pathological analysis of an opened round ligament used as a venous patch graft in a living donor liver transplantation (LDLT). A 13-year-old female patient with biliary atresia underwent LDLT using a posterior segment graft from her mother. The graft had two hepatic veins (HVs), which included the right HV (RHV; 15 mm) and the inferior RHV (IRHV; 20 mm). The graft RHV and IRHV were formed into a single orifice using the donor’s opened round ligament (60 mm × 20 mm) as a patch graft during bench surgery; it was then anastomosed end-to-side with the recipient inferior vena cava. The recipient had no post-transplant complications involving the HVs, but she died of septic shock with persistent cholangitis and jaundice 86 d after LDLT. The HV anastomotic site had no stenosis or thrombus on autopsy. On pathology, there was adequate patency and continuity between the recipient’s HV and the donor’s opened round ligament. In addition, the stains for CD31 and CD34 on the inner membrane of the opened round ligament were positive. Hepatic venous reconstruction using the opened round ligament as a venous patch graft is effective in LDLT, as observed on pathology.
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11
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Abdelaziz O, Attia H. Doppler ultrasonography in living donor liver transplantation recipients: Intra- and post-operative vascular complications. World J Gastroenterol 2016; 22:6145-72. [PMID: 27468207 PMCID: PMC4945976 DOI: 10.3748/wjg.v22.i27.6145] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/18/2016] [Accepted: 06/13/2016] [Indexed: 02/06/2023] Open
Abstract
Living-donor liver transplantation has provided a solution to the severe lack of cadaver grafts for the replacement of liver afflicted with end-stage cirrhosis, fulminant disease, or inborn errors of metabolism. Vascular complications remain the most serious complications and a common cause for graft failure after hepatic transplantation. Doppler ultrasound remains the primary radiological imaging modality for the diagnosis of such complications. This article presents a brief review of intra- and post-operative living donor liver transplantation anatomy and a synopsis of the role of ultrasonography and color Doppler in evaluating the graft vascular haemodynamics both during surgery and post-operatively in accurately defining the early vascular complications. Intra-operative ultrasonography of the liver graft provides the surgeon with useful real-time diagnostic and staging information that may result in an alteration in the planned surgical approach and corrections of surgical complications during the procedure of vascular anastomoses. The relevant intra-operative anatomy and the spectrum of normal and abnormal findings are described. Ultrasonography and color Doppler also provides the clinicians and surgeons early post-operative potential developmental complications that may occur during hospital stay. Early detection and thus early problem solving can make the difference between graft survival and failure.
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12
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One-step venous reconstruction using the donor's round ligament in right-lobe living-donor liver transplantation. Surg Today 2014; 45:522-5. [PMID: 25231939 DOI: 10.1007/s00595-014-1004-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 05/12/2014] [Indexed: 12/12/2022]
Abstract
We herein report the use of an opened round ligament as a venous patch graft for inferior right hepatic vein (IRHV) reconstruction and anastomosis to the inferior vena cava (IVC) in living-donor liver transplantation (LDLT) using a right-lobe (RL) graft. After laparotomy, the donor's round ligament was harvested and opened, and the semi-transparent umbilical vein, which was 7.0 cm in length and 3.0 cm in width, was carefully trimmed on the back table for use as a patch graft. The right hepatic vein of the graft was anastomosed to the harvested patch, and the IRHV was anastomosed to an independent hole made in the wall on the other side of the patch, to form a bridged vascular patch for anastomosis to the IVC. The interposition graft filled promptly and provided a good outflow from the posterior segment. This is the first report of venous reconstruction using a donor's round ligament graft in RL-LDLT.
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Chen P, Wang W, Yan L, Wen T, Li B, Zhao J. Reconstructing middle hepatic vein tributaries in right-lobe living donor liver transplantation. Dig Surg 2014; 31:210-8. [PMID: 25227957 DOI: 10.1159/000363416] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 05/05/2014] [Indexed: 12/10/2022]
Abstract
AIMS To investigate the effectiveness of our technique and policy in reconstructing middle hepatic vein (MHV) tributaries of patients undergoing right-lobe living donor liver transplantation (LDLT). METHODS From January 2001 to December 2010, 186 adult patients underwent right-lobe LDLT without the MHV. Patients were divided into two groups: group A (n = 71) and group B (n = 115) without or with the MHV tributaries reconstruction. We evaluated the serum liver function markers after transplantation and monitored vascular flow in the graft and interpositional vein by Doppler ultrasonography. RESULTS The cumulative 1-, 3-, 5-year graft and patient survival rates were not significant between group A and group B (p = 0.287 and p = 0.258). Biliary complications appeared to be more frequent in group A than in group B (16.9 vs. 5.2%, p = 0.009). Liver function impairment was found in patients without MHV reconstruction and those with occluded interpositional vessels early after transplantation. The cumulative 1-, 3-, 6- and 12-month patency rate of the interpositional veins was 81.51, 79.60, 74.69 and 72.68%, respectively. CONCLUSION The reconstruction technique based on our policy ensures excellent outflow drainage and favorable recipient outcome, while better criteria for MHV reconstruction should be established.
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Affiliation(s)
- Peixian Chen
- Department of Liver and Vascular Surgery, West China Hospital of Sichuan University, Chengdu, PR China
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14
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Multiple Hepatic Vein Reconstruction Using an All-in-one Sleeve Patch Graft Technique in Living Donor Liver Transplantation: A Case Report. Transplant Proc 2014; 46:982-5. [DOI: 10.1016/j.transproceed.2013.11.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/15/2013] [Indexed: 11/22/2022]
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15
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Morita K, Shirabe K, Yoshizumi T, Ikegami T, Masuda T, Hashimoto N, Mano Y, Miyata T, Soejima Y, Maehara Y. Feasible isolated liver transplantation for a cirrhotic patient on chronic hemodialysis. Case Rep Gastroenterol 2013; 7:299-303. [PMID: 23904841 PMCID: PMC3728599 DOI: 10.1159/000354140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
End-stage liver and kidney disease (ELKD) is an indication for deceased donor simultaneous liver-kidney transplantation. Although a few cases of living donor liver-kidney transplantation have been reported, the invasiveness remains to be discussed. Living donor liver transplantation (LDLT) is an alternative choice for ELKD, but has never been reported. Here, we report a case of successful LDLT for a patient with ELKD on hemodialysis. The patient was a 63-year-old male and had decompensated hepatitis C cirrhosis with seronegativity for hepatitis C virus. He had non-diabetic end-stage renal failure and had been on hemodialysis for 3 years. He was in good general condition except for hepatic and renal failure. The living donor was his 58-year-old healthy wife. A right lobe graft was transplanted to the recipient under continuous hemodiafiltration (CHDF) and extracorporeal veno-venous bypass. CHDF was continued until postoperative day 4, at which point CHDF was converted to hemodialysis. His posttransplant course was good and he was discharged on postoperative day 36. To the best of our knowledge, this is the first report of LDLT for a patient on chronic hemodialysis. Therefore, being on hemodialysis is not a contraindication for LDLT. LDLT is feasible for a patient with ELKD on hemodialysis.
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Affiliation(s)
- Kazutoyo Morita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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16
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Ikegami T, Shirabe K, Yoshiya S, Soejima Y, Yoshizumi T, Uchiyama H, Toshima T, Motomura T, Maehara Y. One-step reconstruction of the right inferior hepatic veins using auto-venous grafts in living-donor liver transplantation. Surg Today 2012; 43:769-76. [PMID: 23247889 DOI: 10.1007/s00595-012-0449-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 05/17/2012] [Indexed: 12/24/2022]
Abstract
PURPOSES Reconstruction of the right inferior hepatic vein (RIHV) presents a major technical challenge in living donor liver transplantation (LDLT) using right lobe grafts. METHODS We studied 47 right lobe LDLT grafts with RIHV revascularization, comparing one-step reconstruction, performed post-May 2007 (n = 16), with direct anastomosis, performed pre-May 2007 (n = 31). RESULTS In the one-step reconstruction technique, the internal jugular vein (n = 6), explanted portal vein (n = 5), inferior vena cava (n = 3), and shunt vessels (n = 2) were used as venous patch grafts for unifying the right hepatic vein, RIHVs, and middle hepatic vein tributaries. By 6 months after LDLT, there was no case of occlusion of the reconstructed RIHVs in the one-step reconstruction group, but a cumulative occlusion rate of 18.2 % in the direct anastomosis group. One-step reconstruction required a longer cold ischemic time (182 ± 40 vs. 115 ± 63, p < 0.001) and these patients had higher alanine transaminase values (142 ± 79 vs. 96 ± 46 IU/L, p = 0.024) on postoperative day POD 7. However, the 6-month short-term graft survival rates were 100 % with one-step reconstruction and 83.9 % with direct anastomosis, respectively. CONCLUSION One-step reconstruction of the RIHVs using auto-venous grafts is an easy and feasible technique promoting successful right lobe LDLT.
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Affiliation(s)
- Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 812-8582, Fukuoka, Japan.
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17
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V5-Drainage-Preserved Right Lobe Grafts Improve Graft Congestion for Living Donor Liver Transplantation. Transplantation 2012; 93:929-35. [DOI: 10.1097/tp.0b013e3182488bd8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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18
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Chen CL, Yap AQ, Concejero AM, Liu CY. All-in-one sleeve patch graft venoplasty for multiple hepatic vein reconstruction in living donor liver transplantation. HPB (Oxford) 2012; 14:274-8. [PMID: 22404267 PMCID: PMC3371215 DOI: 10.1111/j.1477-2574.2012.00442.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This paper presents an innovative technique to address complex multiple hepatic vein (HV) reconstruction in right lobe graft living donor liver transplantation (RL-LDLT). METHODS A patient with hepatitis C virus-related cirrhosis underwent RL-LDLT. The graft had seven HVs, including: the right HV (17 mm); one segment VII HV (11 mm); two segment VI HVs (6 mm and 16 mm), and three segment V HVs. The graft weighed 663 g (53% of standard liver volume; ratio of graft weight to recipient body weight: 0.96). Each HV had significant drainage territory requiring reconstruction. A cryopreserved iliac vein graft was used to create a sleeve patch to incorporate the HV openings. The holes were anastomosed to their corresponding HV tributaries using continuous 6-0 polydioxanone (PDS) sutures. Two of the three segment V HVs were combined using a smaller iliac vein patch, which was anastomosed in an end-to-side fashion to a previously harvested recipient umbilical vein interposition graft. The other end of the umbilical vein graft was anastomosed to the larger iliac vein sleeve patch. RESULTS Overall, six HV openings were incorporated in one sleeve patch to allow a single wide anastomosis with the recipient inferior vena cava. Doppler ultrasound after reconstruction showed adequate flow patterns in all the HVs. CONCLUSIONS All-in-one sleeve patch graft venoplasty simplifies the reconstruction of multiple HVs and reduces warm ischaemia time in RL-LDLT with excellent outcomes.
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Affiliation(s)
- Chao-Long Chen
- Liver Transplantation Programme, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Soejima Y, Takeishi K, Ikegami T, Uchiyama H, Taketomi A, Maehara Y. All-in-one ex vivo self-reconstruction technique using an autologous inferior vena cava for a right lobe liver graft with multiple and complex venous orifices. Liver Transpl 2010; 16:909-13. [PMID: 20583093 DOI: 10.1002/lt.22071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Yuji Soejima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Ikegami T, Soejima Y, Nagata S, Taketomi A, Maehara Y. The use of autologous vena cava patch graft for reconstructing multiple outflow orifices in right hemiliver living donor graft. Transpl Int 2009; 22:853-5. [PMID: 19490543 DOI: 10.1111/j.1432-2277.2009.00870.x] [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: 01/26/2023]
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Potential risk in using hepatic veins of a native liver for reconstructing accessory veins in right lobe living donor graft. Transplantation 2009; 88:143-4; author reply 144-5. [PMID: 19584696 DOI: 10.1097/tp.0b013e3181aae502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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