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Fundora Y, Hessheimer AJ, Del Prete L, Maroni L, Lanari J, Barrios O, Clarysse M, Gastaca M, Barrera Gómez M, Bonadona A, Janek J, Boscà A, Álamo Martínez JM, Zozaya G, López Garnica D, Magistri P, León F, Magini G, Patrono D, Ničovský J, Hakeem AR, Nadalin S, McCormack L, Palacios P, Zieniewicz K, Blanco G, Nuño J, Pérez Saborido B, Echeverri J, Bynon JS, Martins PN, López López V, Dayangac M, Lodge JPA, Romagnoli R, Toso C, Santoyo J, Di Benedetto F, Gómez-Gavara C, Rotellar F, Gómez-Bravo MÁ, López Andújar R, Girard E, Valdivieso A, Pirenne J, Lladó L, Germani G, Cescon M, Hashimoto K, Quintini C, Cillo U, Polak WG, Fondevila C. Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis. J Hepatol 2023; 78:794-804. [PMID: 36690281 DOI: 10.1016/j.jhep.2023.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND & AIMS Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. METHODS An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. RESULTS A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001). CONCLUSIONS Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. IMPACT AND IMPLICATIONS Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.
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Affiliation(s)
- Yiliam Fundora
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain
| | - Amelia J Hessheimer
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain; General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Luca Del Prete
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lorenzo Maroni
- Hepatobiliary Surgery & Transplant Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, Italy
| | - Jacopo Lanari
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Oriana Barrios
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Mikel Gastaca
- Hepatobiliary Surgery & Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain
| | - Manuel Barrera Gómez
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Agnès Bonadona
- Grenoble Alpes University, CHU Grenoble Alpes, Digestive Surgery & Liver Transplantation, Grenoble, France
| | - Julius Janek
- Department of Transplant Surgery, F.D. Roosevelt Hospital, Banská Bystrica, Slovakia
| | - Andrea Boscà
- Liver Transplantation & Hepatology Laboratory, Hepatology, HPB Surgery & Transplant Unit, Health Research Institute Hospital La Fe, La Fe University Hospital, Valencia, Spain
| | | | - Gabriel Zozaya
- HPB and Liver Transplant Unit, Clínica Universidad de Navarra; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | | | - Paolo Magistri
- Hepato-pancreato-biliary Surgery & Liver Transplantation Unit, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Francisco León
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Giulia Magini
- Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Damiano Patrono
- General Surgery 2U - Liver Transplant Centre, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Jiří Ničovský
- Centrum Kardiovaskulární a Transplantační Chirurgie, Brno, Czechia
| | - Abdul Rahman Hakeem
- Department of HPB and Liver Transplant Surgery, St. James's University Hospital, Leeds, UK
| | - Silvio Nadalin
- University of Tübingen, Tübingen, Germany; European Liver and Intestine Transplant Association (ELITA) Board
| | | | - Pilar Palacios
- Hospital Clínico Universitario de Zaragoza, Zaragoza, Spain
| | - Krzysztof Zieniewicz
- Medical University of Warsaw, Warsaw, Poland; European Liver and Intestine Transplant Association (ELITA) Board
| | - Gerardo Blanco
- Hospital Universitario de Badajoz, Universidad de Extremadura, Badajoz, Spain
| | - Javier Nuño
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Baltasar Pérez Saborido
- Hepatobiliopancreatic Surgery & Liver Transplant Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Juan Echeverri
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - J Steve Bynon
- University of Texas Houston - Memorial Hermann TMC, Houston, Texas, USA
| | - Paulo N Martins
- University of Massachusetts - Memorial Medical Center, Worcester, Massachusetts, USA
| | - Víctor López López
- Department of Surgery & Transplantation, Hospital Clínico Universitario Virgen de la Arrixaca, Murcian Institue of Biosanitary Research (IMIB), Murcia, Spain
| | - Murat Dayangac
- Medipol University Hospital Center for Organ Transplantation, Istanbul, Turkey
| | - J Peter A Lodge
- Department of HPB and Liver Transplant Surgery, St. James's University Hospital, Leeds, UK
| | - Renato Romagnoli
- General Surgery 2U - Liver Transplant Centre, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Christian Toso
- Hôpitaux Universitaires de Genève, Geneva, Switzerland; European Liver and Intestine Transplant Association (ELITA) Board
| | - Julio Santoyo
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Fabrizio Di Benedetto
- Hepato-pancreato-biliary Surgery & Liver Transplantation Unit, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | | | - Fernando Rotellar
- HPB and Liver Transplant Unit, Clínica Universidad de Navarra; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | | | - Rafael López Andújar
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain; Liver Transplantation & Hepatology Laboratory, Hepatology, HPB Surgery & Transplant Unit, Health Research Institute Hospital La Fe, La Fe University Hospital, Valencia, Spain
| | - Edouard Girard
- Grenoble Alpes University, CHU Grenoble Alpes, Digestive Surgery & Liver Transplantation, Grenoble, France
| | - Andrés Valdivieso
- Hepatobiliary Surgery & Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain
| | - Jacques Pirenne
- Abdominal Transplant Surgery, UZ Leuven, KUL, Leuven, Belgium
| | - Laura Lladó
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Giacomo Germani
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy; European Liver and Intestine Transplant Association (ELITA) Board
| | - Matteo Cescon
- Hepatobiliary Surgery & Transplant Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, Italy
| | - Koji Hashimoto
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cristiano Quintini
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Umberto Cillo
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Wojciech G Polak
- Division of HPB & Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands; European Liver and Intestine Transplant Association (ELITA) Board
| | - Constantino Fondevila
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain; General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain; European Liver and Intestine Transplant Association (ELITA) Board.
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Zhao D, Huang YM, Liang ZM, Zhang KJ, Fang TS, Yan X, Jin X, Zhang Y, Tang JX, Xie LJ, Zeng XC. Reconstructing the portal vein through a posterior pancreatic tunnel: New choice for portal vein thrombosis during liver transplantation. World J Gastrointest Surg 2022; 14:1131-1140. [PMID: 36386397 PMCID: PMC9640334 DOI: 10.4240/wjgs.v14.i10.1131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/08/2022] [Accepted: 09/21/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Thrombectomy and anatomical anastomosis (TAA) has long been considered the optimal approach to portal vein thrombosis (PVT) in liver transplantation (LT). However, TAA and the current approach for non-physiological portal reconstructions are associated with a higher rate of complications and mortality in some cases.
AIM To describe a new choice for reconstructing the portal vein through a posterior pancreatic tunnel (RPVPPT) to address cases of unresectable PVT.
METHODS Between August 2019 and August 2021, 245 adult LTs were performed. Forty-five (18.4%) patients were confirmed to have PVT before surgery, among which seven underwent PV reconstruction via the RPVPPT approach. We retrospectively analyzed the surgical procedure and postoperative complications of these seven recipients that underwent PV reconstruction due to PVT.
RESULTS During the procedure, PVT was found in all the seven cases with significant adhesion to the vascular wall and could not be dissected. The portal vein proximal to the superior mesenteric vein was damaged in one case when attempting thrombolectomy, resulting in massive bleeding. LT was successfully performed in all patients with a mean duration of 585 min (range 491-756 min) and mean intraoperative blood loss of 800 mL (range 500-3000 mL). Postoperative complications consisted of chylous leakage (n = 3), insufficient portal venous flow to the graft (n = 1), intra-abdominal hemorrhage (n = 1), pulmonary infection (n = 1), and perioperative death (n = 1). The remaining six patients survived at 12-17 mo follow-up.
CONCLUSION The RPVPPT technique might be a safe and effective surgical procedure during LT for complex PVT. However, follow-up studies with large samples are still warranted due to the relatively small number of cases.
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Affiliation(s)
- Dong Zhao
- Department of Liver Surgery and Organ Transplantation Center, The Third People’s Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China
| | - Yi-Ming Huang
- Department of Liver Surgery and Organ Transplantation Center, The Third People’s Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China
| | - Zi-Ming Liang
- Department of Liver Surgery and Organ Transplantation Center, The Third People’s Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China
| | - Kang-Jun Zhang
- Department of Liver Surgery and Organ Transplantation Center, The Third People’s Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China
| | - Tai-Shi Fang
- Department of Liver Surgery and Organ Transplantation Center, The Third People’s Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China
| | - Xu Yan
- Department of Liver Surgery and Organ Transplantation Center, The Third People’s Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China
| | - Xin Jin
- Department of Liver Surgery and Organ Transplantation Center, The Third People’s Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China
| | - Yi Zhang
- Department of Liver Surgery and Organ Transplantation Center, The Third People’s Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China
| | - Jian-Xin Tang
- Department of Liver Surgery and Organ Transplantation Center, The Third People’s Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China
| | - Lin-Jie Xie
- Department of Liver Surgery and Organ Transplantation Center, The Third People’s Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China
| | - Xin-Chen Zeng
- Department of Liver Surgery and Organ Transplantation Center, The Third People’s Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Disease, Shenzhen 518000, Guangdong Province, China
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3
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Perfecto A, Gastaca M, Prieto M, Palomares I, Ventoso A, Ruiz P, Mambrilla S, Muga E, Senosiain M, Salvador P, Testillano M, Fernández JR, Bustamante FJ, Valdivieso A. Renoportal Anastomosis and Its Complications: A Complex Case Report. Transplant Proc 2022; 54:2552-2555. [DOI: 10.1016/j.transproceed.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/22/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022]
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4
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Pinelli D, Neri F, Tornese S, Amaduzzi A, Camagni S, D'Antiga L, Fagiuoli S, Colledan M. Physiological reno-portal bypass in liver transplantation with non-tumorous portal vein thrombosis. Updates Surg 2022; 74:1617-1626. [PMID: 35441945 DOI: 10.1007/s13304-022-01280-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 03/11/2022] [Indexed: 11/25/2022]
Abstract
Reno-portal anastomosis (RPA) in presence of spleno-renal shunts (SRS) is a physiological option to restore blood flow in liver transplantation with portal vein thrombosis (PVT). Diffuse splanchnic venous system thrombosis (complex PVT) is its main indication but RPA proved to be useful in selected cases of less extensive thrombosis (non-complex PVT). Up until now only two monocentric and one multicentric case series has been published on this topic in addition to few anecdotal reports. After 2014, we introduced RPA in our institution to manage some cases of complex PVT in presence of SRS. Here, we present the evolution of indication to RPA. From 2014 to 2020, we performed ten RPA: nine patients presented non-complex and one complex PVT. Overall early and late complication rates were 66.6% and 50%, respectively. Two patients developed RPA stenosis, treated by interventional radiology. Self-resolving acute kidney injury (AKI) was observed in three cases. No re-transplantation was necessary. RPA was patent in all patients, with a mean follow-up of 41.9 months. The overall patient survival was 70% at 1 year and 60% at 3 and 5 years. Four patients died at 1, 2, 3 and 20 months from LT. Causes of deaths were, respectively, stroke, cerebral infection, sepsis (MOF) and sudden variceal bleeding in sinusoidal obstruction syndrome. The relative simplicity and effectiveness of RPA in presence of SRS allowed us to rely more and more often on this technique in liver transplantation with challenging non-complex PVT.
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Affiliation(s)
- Domenico Pinelli
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy.
| | - Flavia Neri
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Stefania Tornese
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Annalisa Amaduzzi
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Stefania Camagni
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Stefano Fagiuoli
- Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Michele Colledan
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
- Università di Milano - Bicocca, Piazza dell'Ateneo Nuovo, 1, 20126, Milano, MI, Italy
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5
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Lin GL, Xiao M, Zhuang L, Yang Y, Li QY, Lu JF, Li MX, Zheng SS. Combination of renoportal anastomosis and inferior mesenteric vein-portal anastomosis in liver transplantation: A new portal reconstruction technique. Hepatobiliary Pancreat Dis Int 2022; 21:182-185. [PMID: 34412966 DOI: 10.1016/j.hbpd.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 07/02/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Guo-Ling Lin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
| | - Min Xiao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
| | - Li Zhuang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
| | - Yu Yang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
| | - Qi-Yong Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
| | - Jian-Fang Lu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Nursing, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
| | - Meng-Xia Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang University School of Medicine, Hangzhou, China
| | - Shu-Sen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China; Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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6
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Wei B, Huang Z, Tang C. Optimal Treatment for Patients With Cavernous Transformation of the Portal Vein. Front Med (Lausanne) 2022; 9:853138. [PMID: 35402447 PMCID: PMC8987530 DOI: 10.3389/fmed.2022.853138] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/21/2022] [Indexed: 01/10/2023] Open
Abstract
Cavernous transformation of the portal vein (CTPV) is a sequela of extrahepatic and/or intrahepatic portal vein obstruction caused by a combination of local and risk factors. It was ever taken as a relatively rare disease due to its scant literature, which was mainly based on clinical series and case reports. CTPV often manifests as gastroesophageal variceal bleeding, splenomegaly, and portal biliopathy after the long-term insidious presentation. It is unable for CTPV to be recanalized with anticoagulation because it is a complete obstruction of the mesentericoportal axis. Endoscopic therapy is mainly used for temporary hemostasis in acute variceal bleeding. Meso-Rex shunting characterized by portal-flow-preserving shunts has been widely performed in children with CTPV. The multitude of complications associated with CTPV in adults can be effectively addressed by various interventional vascular therapies. With the ubiquity of radiological examinations, optimal treatment for patients with CTPV becomes important. Multivisceral transplantation, such as liver-small intestinal transplantation, may be lifesaving and should be considered for patients with diffuse mesenteric venous thrombosis.
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Affiliation(s)
- Bo Wei
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyin Huang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Chengwei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Chengwei Tang
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Pinelli D, Camagni S, Amaduzzi A, Frosio F, Fontanella L, Carioli G, Guizzetti M, Zambelli MF, Giovanelli M, Fagiuoli S, Colledan M. Liver transplantation in patients with non-neoplastic portal vein thrombosis: 20 years of experience in a single center. Clin Transplant 2021; 36:e14501. [PMID: 34633110 DOI: 10.1111/ctr.14501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/14/2021] [Accepted: 09/25/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND The Yerdel classification is widely used for describing the severity of portal vein thrombosis (PVT) in liver transplant (LT) candidates, but might not accurately predict transplant outcome. METHODS We retrospectively analyzed data regarding 97 adult patients with PVT who underwent LT, investigating whether the complexity of portal reconstruction could better correlate with transplant outcome than the site and extent of the thrombosis. RESULTS 79/97 (80%) patients underwent thrombectomy and anatomical anastomosis (TAA), 18/97 (20%) patients underwent non-anatomical physiological reconstructions (non-TAA). PVT Yerdel grade was 1-2 in 72/97 (74%) patients, and 3-4 in 25/97 (26%) patients. Univariate analysis revealed higher 30-day mortality, 90-day mortality, 1-year mortality, and a higher rate of severe early complications in the non-TAA group than in the TAA group (p = .018, .001, .014, .009, respectively). In the model adjusted for PVT Yerdel grade, non-TAA remained independently associated with higher 30-day, 90-day, and 1-year mortality (p = .021, .007, and .015, respectively). The portal vein re-thrombosis and overall patient and graft survival rates were similar. DISCUSSION In our experience, the complexity of portal reconstruction better correlated with transplant outcome than the Yerdel classification, which did not even appear to be a reliable predictor of the surgical complexity and technique.
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Affiliation(s)
- Domenico Pinelli
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Stefania Camagni
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Annalisa Amaduzzi
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Fabio Frosio
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Laura Fontanella
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Greta Carioli
- FROM Research Foundation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Michela Guizzetti
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - Mara Giovanelli
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Stefano Fagiuoli
- Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Michele Colledan
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
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Maruyama H, Shiina S. Collaterals in portal hypertension: anatomy and clinical relevance. Quant Imaging Med Surg 2021; 11:3867-3881. [PMID: 34341755 DOI: 10.21037/qims-20-1328] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/07/2021] [Indexed: 12/14/2022]
Abstract
Portal hypertension is a key pathophysiology of chronic liver diseases typified with cirrhosis or noncirrhotic portal hypertension. The development of collateral vessels is a characteristic feature of impaired portal hemodynamics. The paraumbilical vein (PUV), left gastric vein (LGV), posterior gastric vein (PGV), short gastric vein (SGV), splenorenal shunt (SRS), and inferior mesenteric vein (IMV) are major collaterals, and there are some rare collaterals. The degree and hemodynamics of collateral may affect the portal venous circulation and may compensate for the balance between inflow and outflow volume of the liver. Additionally, the development of collateral shows a relation with the liver function reserve and clinical manifestations such as esophageal varices (EV), gastric varices, rectal varices and the other ectopic varices, hepatic encephalopathy, and prognosis. Furthermore, there may be an interrelationship in the development between different collaterals, showing additional influences on the clinical presentations. Thus, the assessment of collaterals may enhance the understanding of the underlying pathophysiology of the condition of patients with portal hypertension. This review article concluded that each collateral has a specific function depending on the anatomy and hemodynamics and is linked with the relative clinical presentation in patients with portal hypertension. Imaging modalities may be essential for the detection, grading and evaluation of the role of collaterals and may help to understand the pathophysiology of the patient condition. Further investigation in a large-scale study would elucidate the basic and clinical significance of collaterals in patients with portal hypertension and may provide information on how to manage them to improve the prognosis as well as quality of life.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | - Shuichiro Shiina
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
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9
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Chedid MF, Zahler S, Chedid AD, Leipnitz I, Prediger JE, Giampaoli AZD, Lopes BB, Kruel CRP, Grezzana-Filho TJM. Liver transplantation in the setting of a spontaneous shunt between superior mesenteric vein and right renal vein. Ann Hepatol 2021; 19:335-337. [PMID: 31594757 DOI: 10.1016/j.aohep.2019.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/30/2019] [Accepted: 08/12/2019] [Indexed: 02/04/2023]
Abstract
Shunts between the superior mesenteric vein (SMV) and the right renal vein (RRV) are very rare. Here, we describe and depict the rare case of a liver transplant (LT) in the setting of shunt between SMV and RRV. A 67-year-old white man presenting with Child C cirrhosis secondary to hemochromatosis and persistent encephalopathy was listed for LT. Preoperative abdominal angiotomography revealed the presence of a large spontaneous shunt between the SMV and the RRV. The patient underwent LT by receiving a liver from a 17-year-old brain-dead deceased donor victim of trauma. A large shunt between the SMV and the RRV was confirmed intraoperatively. Although there was no portal vein (PV) thrombosis, the PV was atrophic and had a reduced flow. PV pressure was 22mmHg (an arterial line was inserted inside the PV stump, and this line was connected to a common pressure transducer, the pressure readings was expressed in the anesthesia monitor). After shunt ligation PV pressure increased to 32mmHg. There were no post-transplant vascular complications, and the patient was discharged home in good health. Preoperative study of all LT candidates with angio CT scan is mandatory. Whenever there is PV thrombosis, an attempt to remove the entire thrombus is warranted. After thrombectomy or whenever there is not PV thrombosis, all large shunts should be ligated. PV pressure and flow should be measured before and after shunt ligation. In the absence of PV thrombosis, ligation of the shunt should enable an increase in PV flow and pressure, as reported herein.
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Affiliation(s)
- Marcio F Chedid
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Porto Alegre, Brazil.
| | - Sofia Zahler
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Porto Alegre, Brazil
| | - Aljamir D Chedid
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Porto Alegre, Brazil
| | - Ian Leipnitz
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Porto Alegre, Brazil
| | - João E Prediger
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Porto Alegre, Brazil
| | - Angelo Z D Giampaoli
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Porto Alegre, Brazil
| | - Bruno B Lopes
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Porto Alegre, Brazil
| | - Cleber R P Kruel
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Porto Alegre, Brazil
| | - Tomaz J M Grezzana-Filho
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Medical School of UFRGS, Porto Alegre, Brazil
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10
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D'Amico G, Matsushima H, Del Prete L, Diago Uso T, Armanyous SR, Hashimoto K, Eghtesad B, Fujiki M, Aucejo F, Sasaki K, Kwon CHD, Simioni A, Miller C, Quintini C. Long term outcomes and complications of reno-portal anastomosis in liver transplantation: results from a propensity score-based outcome analysis. Transpl Int 2021; 34:1938-1947. [PMID: 34008257 DOI: 10.1111/tri.13920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/29/2021] [Accepted: 05/11/2021] [Indexed: 12/23/2022]
Abstract
Diffuse splanchnic vein thrombosis (DSVT) remains a serious challenge in liver transplantation (LT). Reno-portal anastomosis (RPA) has previously been reported as a valid option for management of patients with DSVT during LT. The aim of this study was to evaluate post-transplant renal function and surgical outcomes of patients with DSVT who underwent RPA during LT. Between January 2005 and December 2017, 1270 patients underwent LT at our institution, including 16 with DSVT managed with RPA (RPA group). We compared renal function and surgical outcomes in these patients to outcomes in 48 propensity score (PS)-matched patients without thrombosis (control group), using a 1:3 matching model. The two groups had similar rates of postoperative portal vein thrombosis (PVT), renal dysfunction as measured by estimated glomerular filtration rate (eGFR), and overall postoperative complications (Clavien grade III), although the RPA group had a higher incidence of postoperative upper gastrointestinal (GI) bleeding (31.3% vs 4.2%; P = 0.009) that had no clinical consequence. There were no significant differences in five-year graft and patient survival rates between the groups (P = 0.133 and P = 0.166, respectively). RPA is an established technique in the management of patients with DSVT during LT, with comparable outcomes to patients without thrombosis. Our report is the first to demonstrate similar surgical outcomes, including long-term renal function, in LT recipients with or without RPA.
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Affiliation(s)
| | | | - Luca Del Prete
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Bijan Eghtesad
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Federico Aucejo
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Kazunari Sasaki
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | | | - Andrea Simioni
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Charles Miller
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
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11
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Puri Y, Gunasekaran V, Palanisamy SK, Elangovan B, Krishna P, Balasubramanian B, Ananth A, Reddy MS, Rela M. A Novel Technique of Physiological Portal Inflow Augmentation During Liver Transplantation for Yerdel Grade 4 Portal Vein Thrombosis. Liver Transpl 2020; 26:294-298. [PMID: 31724287 DOI: 10.1002/lt.25680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/29/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Yogesh Puri
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | | | - Shiva Kumar Palanisamy
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Babu Elangovan
- Department of Surgical Gastroenterology and Liver Transplant, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Pradeep Krishna
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Balaji Balasubramanian
- Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Anjana Ananth
- Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Mettu Srinivas Reddy
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Mohamed Rela
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
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12
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Liver Transplantation. THE CRITICALLY ILL CIRRHOTIC PATIENT 2020. [PMCID: PMC7122092 DOI: 10.1007/978-3-030-24490-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The field of liver transplantation has changed since the MELD scoring system became the most widely used donor allocation tool. Due to the MELD-based allocation system, sicker patients with higher MELD scores are being transplanted. Persistent organ donor shortages remain a challenging issue, and as a result, the wait-list mortality is a persistent problem for most of the regions. This chapter focuses on deceased donor and live donor liver transplantation in patients with complications of portal hypertension. Special attention will also be placed on donor-recipient matching, perioperative management of transplant patients, and the impact of hepatic hemodynamics on transplantation.
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13
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Bhangui P, Lim C, Levesque E, Salloum C, Lahat E, Feray C, Azoulay D. Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation. J Hepatol 2019; 71:1038-1050. [PMID: 31442476 DOI: 10.1016/j.jhep.2019.08.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/25/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023]
Abstract
Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.
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Affiliation(s)
- Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, New Delhi, India
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Paris, France
| | - Eric Levesque
- Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel
| | - Cyrille Feray
- Department of Hepatology, Paul Brousse Hospital, Villejuif, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France; Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel.
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14
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D'Amico G, Hassan A, Diago Uso T, Hashmimoto K, Aucejo FN, Fujiki M, Eghtesad B, Sasaki K, Lindenmeyer CC, Miller CM, Quintini C. Renoportal anastomosis in liver transplantation and its impact on patient outcomes: a systematic literature review. Transpl Int 2018; 32:117-127. [DOI: 10.1111/tri.13368] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 06/28/2018] [Accepted: 10/19/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Giuseppe D'Amico
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Ahmed Hassan
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Teresa Diago Uso
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Koji Hashmimoto
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Federico N. Aucejo
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Masato Fujiki
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Bijan Eghtesad
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Kazunari Sasaki
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Christina C. Lindenmeyer
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Charles M. Miller
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Cristiano Quintini
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
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15
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Grezzana-Filho TJM, Chedid MF, Chedid AD, Bassani-Filho EL, Pereira PF, Leipnitz I, Backes AN, Kruel CRP. How to do liver transplantation using renoportal bypass. ANZ J Surg 2017; 88:236-237. [PMID: 29216680 DOI: 10.1111/ans.14299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Tomaz J M Grezzana-Filho
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Marcio F Chedid
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Aljamir D Chedid
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Ernidio L Bassani-Filho
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Pedro F Pereira
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Ian Leipnitz
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Ariane N Backes
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Cleber R P Kruel
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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16
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Nazzal M, Sun Y, Okoye O, Diggs L, Evans N, Osborn T, Etesami K, Varma C. Reno-portal shunt for liver transplant, an alternative inflow for recipients with grade III-IV portal vein thrombosis: Tips for a better outcome. Int J Surg Case Rep 2017; 41:251-254. [PMID: 29102862 PMCID: PMC5742012 DOI: 10.1016/j.ijscr.2017.09.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Portal vein thrombosis (PVT) poses an extremely difficult problem in cirrhotic patients who are in need of a liver transplant. The prevalence of PVT in patients with cirrhosis ranges from 0.6% to 26% Nery et al. (2015) [1]. The presence of PVT is associated with more technically difficult liver transplant and in certain cases can be a contraindication to liver transplant. The only option for these patients with extensive PVT would be a multi-visceral transplant, the later unfortunately has a much higher morbidity and mortality compared to liver only transplant Smith et al. (2016) [2]. An alternative approach is needed to provide a safe and reliable outcome. PRESENTATION OF CASE In this case series, we present our experience with reno-portal shunt as an alternative inflow for the liver allograft. DISCUSSION This approach appears to be safe with good long-term outcome.Although this technique has been described before, we provide additional considerations that produced good outcomes in our patients. CONCLUSION We believe that meticulous preoperative planning with high-resolution triple phase CT imaging with a measurement of the diameter of the spleno-renal shunt along with a duplex scan measuring flow through the shunt is key to a successful transplantation. Moreover, appropriate donor liver size is also of extreme importance to avoid portal hypoperfusion.
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Affiliation(s)
- Mustafa Nazzal
- Center for Abdominal Transplantation, Saint Louis University, United States.
| | - Yifei Sun
- Department of General Surgery, Saint Louis University, United States
| | - Obi Okoye
- Department of General Surgery, Saint Louis University, United States
| | - Laurence Diggs
- Department of General Surgery, Saint Louis University, United States
| | - Neil Evans
- Saint Louis University School of Medicine, United States
| | - Tamara Osborn
- Saint Louis University School of Medicine, United States
| | - Kambiz Etesami
- Center for Abdominal Transplantation, Saint Louis University, United States
| | - Chintalapati Varma
- Center for Abdominal Transplantation, Saint Louis University, United States
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17
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Aktas H, Ozer A, Guner O, Gurluler E, Emiroglu R. Liver Transplantation in Patients With Complete Portal Vein Thrombosis: Renoportal or Varicoportal Anastomosis Using Cryopreserved Vein Grafts. Transplant Proc 2017; 49:1820-1823. [DOI: 10.1016/j.transproceed.2017.06.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/14/2017] [Accepted: 06/01/2017] [Indexed: 12/13/2022]
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18
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Ogasawara H, Nakanishi C, Miyagi S, Tokodai K, Hara Y, Nakanishi W, Miyazawa K, Shimizu K, Kumata H, Goto H, Goto M, Unno M, Kamei T. Renoportal Anastomosis in Left Lateral Lobe Living Donor Liver Transplantation: A Pediatric Case. Case Rep Gastroenterol 2017; 11:584-592. [PMID: 29118687 PMCID: PMC5662992 DOI: 10.1159/000481160] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/29/2017] [Indexed: 12/13/2022] Open
Abstract
In adult liver transplantation, renoportal anastomosis (RPA) has been introduced as a useful technique for patients with grade 4 portal vein thrombosis and a splenorenal shunt. Here, we report a pediatric case in which RPA allowed a left lateral lobe living donor liver transplantation (LDLT) despite portal vein thrombosis and a large splenorenal shunt. At 36 days old, the patient underwent a Kasai operation for biliary atresia. At 17 months old, she underwent LDLT because of repetitive cholangitis. Pretransplant examinations revealed a large splenorenal shunt and portal vein thrombosis. Simple end-to-end portal reconstruction and clamping of the collateral route after removing the thrombosis were unsuccessful. Thus, RPA was performed using a donor superficial femoral vein as an interpositional graft. The portal vein pressure was 20 mm Hg after arterial reperfusion. Ligation of the splenic artery reduced the portal vein pressure. Although she developed severe acute cellular rejection and chylous ascites, there were no signs of portal vein complications. She was discharged 73 days after transplantation without any signs of renal dysfunction. The patient's condition was good at her last follow-up, 22 months after transplantation. To our knowledge, this is the youngest case of RPA in pediatric left lateral lobe LDLT. Additionally, this is the first case of RPA with splenic artery ligation and using the donor's superficial femoral vein as the venous graft for RPA. Although long-term follow-up is necessary, RPA could be a salvage option in LDLT in infants if other methods are unsuccessful.
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Affiliation(s)
- Hiroyuki Ogasawara
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Chikashi Nakanishi
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Shigehito Miyagi
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Kazuaki Tokodai
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Yasuyuki Hara
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Wataru Nakanishi
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Koji Miyazawa
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Kenji Shimizu
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Hiroyuki Kumata
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Hitoshi Goto
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Masafumi Goto
- Division of Transplantation and Regenerative Medicine, Tohoku University, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Takashi Kamei
- Department of Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
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19
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Draoua M, Titze N, Gupta A, Fernandez HT, Ramsay M, Saracino G, McKenna G, Testa G, Klintmalm GB, Kim PTW. Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplantations with portal vein thrombosis. Liver Transpl 2017; 23:1032-1039. [PMID: 28425187 DOI: 10.1002/lt.24779] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 03/07/2017] [Accepted: 03/16/2017] [Indexed: 02/07/2023]
Abstract
Adequate portal vein (PV) flow in liver transplantation is essential for a good outcome, and it may be compromised in patients with portal vein thrombosis (PVT). This study evaluated the impact of intraoperatively measured PV flow after PV thrombendvenectomy on outcomes after deceased donor liver transplantation (DDLT). The study included 77 patients over a 16-year period who underwent PV thrombendvenectomy with complete flow data. Patients were classified into 2 groups: high PV flow (>1300 mL/minute; n = 55) and low PV flow (≤1300 mL/minute; n = 22). Postoperative complications and graft survival were analyzed according to the PV flow. The 2 groups were similar in demographic characteristics. Low PV flow was associated with higher cumulative rates of biliary strictures (P = 0.02) and lower 1-, 2-, and 5-year graft survival (89%, 85%, and 68% versus 64%, 55%, and 38%, respectively; P = 0.002). There was no difference in the incidence of postoperative PVT between the groups (1.8% versus 9.1%; P = 0.19). No biliary leaks or hepatic artery thromboses were reported in either group. By multivariate analyses, age >60 years (hazard ratio [HR], 3.04, 95% confidence interval [CI], 1.36-6.82; P = 0.007) and low portal flow (HR, 2.31; 95% CI, 1.15-4.65; P = 0.02) were associated with worse survival. In conclusion, PV flow <1300 mL/minute after PV thrombendvenectomy for PVT during DDLT was associated with higher rates of biliary strictures and worse graft survival. Consideration should be given to identifying reasons for low flow and performing maneuvers to increase PV flow when intraoperative PV flows are <1300 mL/minute. Liver Transplantation 23 1032-1039 2017 AASLD.
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Affiliation(s)
| | - Nicole Titze
- Department of Pediatrics, University of California, Irvine, CA
| | - Amar Gupta
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Hoylan T Fernandez
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Michael Ramsay
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giovanna Saracino
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Gregory McKenna
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Goran B Klintmalm
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Peter T W Kim
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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20
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Seal JB, Bohorquez H, Battula N, DeGregorio L, Bugeaud E, Bruce DS, Carmody IC, Cohen AJ, Loss GE. Balloon-Occlusion Technique for Managing Portal Vein Hemorrhage in Liver Transplantation. Ochsner J 2017; 17:76-79. [PMID: 28331452 PMCID: PMC5349641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) is relatively common among candidates for liver transplantation and can present significant intraoperative challenges. Depending on the extent of PVT, thromboendovenectomy (TEV), portal bypass, or systemic inflow may be required to restore portal inflow. While TEV is the most commonly used approach to restore anatomic portal inflow, portal vein injury and life-threatening hemorrhage are risks with this technique. CASE REPORT We present a salvage technique for managing portal vein injury during TEV using intraluminal balloon occlusion of the portal vein during portal vein repair and reconstruction. This alternative mode of bleeding control optimizes exposure to the retropancreatic space and avoids direct application of vascular clamps that can cause further injury to the vessel and surrounding tissue. CONCLUSION Careful preoperative planning and anticipation of potential problems are essential for safe and effective management of complex PVT intraoperatively. The balloon-occlusion technique can facilitate safe and efficient repair of a portal vein injury during TEV for liver transplantation.
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Affiliation(s)
- John B. Seal
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Humberto Bohorquez
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Naren Battula
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Lucia DeGregorio
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Emily Bugeaud
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - David S. Bruce
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Ian C. Carmody
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Ari J. Cohen
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - George E. Loss
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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21
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Stine JG, Argo CK, Pelletier SJ, Maluf DG, Northup PG. Liver transplant recipients with portal vein thrombosis receiving an organ from a high-risk donor are at an increased risk for graft loss due to hepatic artery thrombosis. Transpl Int 2016; 29:1286-1295. [PMID: 27714853 DOI: 10.1111/tri.12855] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/23/2016] [Accepted: 09/02/2016] [Indexed: 12/11/2022]
Abstract
We hypothesize that recipients with pretransplant portal vein thrombosis (PVT) receiving organs from high-risk donors (HRD) are at an increased risk of HAT. Data on all liver transplants in the United States from February 2002 to March 2015 were analyzed. Recipients were sorted into two groups: those with PVT and those without. HRDs were defined by donor risk index (DRI) >1.7. Multivariable logistic regression models were constructed to assess the independent risk factors for HAT with the resultant graft loss ≤90 days from transplantation. A total of 60 404 candidates underwent liver transplantation; of those recipients, 623 (1.0%) had HAT, of which 66.0% (n = 411) received organs from HRDs compared with 49.3% (n = 29 473) in recipients without HAT (P < 0.001); 2250 (3.7%) recipients had pretransplantation PVT and received organs from HRDs. On adjusted multivariable analysis, PVT with a HRD organ was the most significant independent risk factor (OR 3.56, 95% CI 2.52-5.02, P < 0.001) for the development of HAT. Candidates with pretransplant PVT who receive an organ from a HRD are at the highest risk for postoperative HAT independent of other measurable factors. Recipients with pretransplant PVT would benefit from careful donor selection and possibly anticoagulation perioperatively.
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Affiliation(s)
- Jonathan G Stine
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, University of Virginia, Charlottesville, VA, USA
| | - Curtis K Argo
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, University of Virginia, Charlottesville, VA, USA
| | - Shawn J Pelletier
- Division of Transplant, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Daniel G Maluf
- Division of Transplant, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Patrick G Northup
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, University of Virginia, Charlottesville, VA, USA
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22
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Chen H, Turon F, Hernández-Gea V, Fuster J, Garcia-Criado A, Barrufet M, Darnell A, Fondevila C, Garcia-Valdecasas JC, Garcia-Pagán JC. Nontumoral portal vein thrombosis in patients awaiting liver transplantation. Liver Transpl 2016; 22:352-65. [PMID: 26684272 DOI: 10.1002/lt.24387] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/06/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis (PVT) occurs in approximately 2%-26% of the patients awaiting liver transplantation (LT) and is no longer an absolute contraindication for LT. Nearly half of PVT cases are accidentally found during the LT procedure. The most important risk factor for PVT development in cirrhosis may be the severity of liver disease and reduced portal blood flow. Whether other inherited or acquired coagulation disorders also play a role is not yet clear. The development of PVT may have no effect on the liver disease progression, especially when it is nonocclusive. PVT may not increase the risk of wait-list mortality, but it is a risk factor for poor early post-LT mortality. Anticoagulation and transjugular intrahepatic portosystemic shunt (TIPS) are 2 major treatment strategies for patients with PVT on the waiting list. The complete recanalization rate after anticoagulation is approximately 40%. The role of TIPS to maintain PV patency for LT as the primary indication has been reported, but the safety and efficacy should be further evaluated. PVT extension and degree may determine the surgical technique to be used during LT. If a "conventional" end-to-end portal anastomotic technique is used, there is not a major impact on post-LT survival. Post-LT PVT can significantly reduce both graft and patient survival after LT and can preclude future options for re-LT.
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Affiliation(s)
- Hui Chen
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Josep Fuster
- HBP Surgery and Liver Transplantation Unit, University of Barcelona, Barcelona, Spain
| | - Angeles Garcia-Criado
- Department of Radiology, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Marta Barrufet
- Department of Radiology, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Anna Darnell
- Department of Radiology, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Constantino Fondevila
- HBP Surgery and Liver Transplantation Unit, University of Barcelona, Barcelona, Spain
| | | | - Juan Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
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23
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Benzing C, Krezdorn N, Förster J, Hinz A, Atanasov G, Wiltberger G, Morgül MH, Lange UG, Schmelzle M, Hau HM, Bartels M. Impact of different immunosuppressive regimens on the health-related quality of life following orthotopic liver transplantation. Clin Transplant 2015; 29:1081-9. [PMID: 26358681 DOI: 10.1111/ctr.12631] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND The influence of immunosuppression on the recipients' quality of life (QoL) is of major importance after OLT and has not yet been evaluated. METHODS The impact of different immunosuppression regimens after OLT was evaluated in 275 patients using the Short Form 36 (SF-36) survey. The following immunosuppressive strategies were compared: (a) CNI, (b) mTOR inhibitors, and (c) mTOR combined with CNI. All regimens were prescribed alone (mono) or in combination (+) with prednisolone and/or mycophenolate mofetil (MMF). RESULTS Highest scores were evident in patients in the mTOR+ group. There were significantly higher values for general health perceptions (GH, p = 0.049), vitality (VIT, p = 0.020), and physical component summary (PCS, p = 0.041) when compared to CNImono and for GH (p = 0.042) and VIT (p = 0.043), when compared to mTORmono. Early conversion to mTOR inhibitors (<two months after OLT) was associated with higher values for 7 of 10 scales, when compared to a late conversion (>two months after OLT), with a statistically significant improvement for the dimension role-emotional (RE, p = 0.027). DISCUSSION mTOR inhibitor-based regimens appear to have beneficial effects on QoL after OLT, especially after an early conversion.
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Affiliation(s)
- Christian Benzing
- Department of Visceral, Thoracic, Transplant and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Nicco Krezdorn
- Department of Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Julia Förster
- Department of Visceral, Thoracic, Transplant and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Andreas Hinz
- Department of Medical Psychology and Medical Sociology, University Hospital of Leipzig, Leipzig, Germany
| | - Georgi Atanasov
- Department of Visceral, Thoracic, Transplant and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Georg Wiltberger
- Department of Visceral, Thoracic, Transplant and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Mehmet H Morgül
- Department of Visceral, Thoracic, Transplant and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Undine G Lange
- Department of Visceral, Thoracic, Transplant and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Moritz Schmelzle
- Department of General, Visceral and Transplant Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hans-Michael Hau
- Department of Visceral, Thoracic, Transplant and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Michael Bartels
- Department of Visceral, Thoracic, Transplant and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
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24
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McKenna GJ. Making the extraordinary, ordinary: renoportal bypass for complete portal vein thrombosis. Liver Transpl 2015; 21:275-6. [PMID: 25678340 DOI: 10.1002/lt.24091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 01/18/2015] [Indexed: 01/17/2023]
Affiliation(s)
- Greg J McKenna
- Department of Surgery, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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