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Sampaio RL, Coelho GR, Mesquita DFG, Soares CEL, Garcia JHP. Left Gastric Vein Direct Anastomosis as Alternative to Portal Flow Reconstruction in Liver Transplantation. ANNALS OF SURGERY OPEN 2024; 5:e382. [PMID: 38883933 PMCID: PMC11175875 DOI: 10.1097/as9.0000000000000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 01/08/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction The most relevant limiting factor for performing end-to-end anastomosis is portal vein thrombosis (PVT), which leads to challenging vascular reconstructions. This study aimed to analyze a single center's experience using the left gastric vein (LGV) for portal flow reconstruction in liver transplantation (LT). Methods This retrospective observational study reviewed laboratory and imaging tests, a description of the surgical technique, and outpatient follow-up of patients with portal system thrombosis undergoing LT with portal flow reconstruction using the LGV. This study was conducted at a single transplant reference center in the northeast region of Brazil from January 2016 to December 2021. Results Between January 2016 and December 2021, 848 transplants were performed at our center. Eighty-two patients (9.7%) presented with PVT, most of whom were treated with thrombectomy. Nine patients (1.1% with PVT) had extensive thrombosis of the portal system (Yerdel III or IV), which required end-to-side anastomosis between the portal vein and the LGV without graft, and had no intraoperative complications. All patients had successful portal flow in Doppler ultrasound control evaluations. Discussion The goal was to reestablish physiological flow to the graft. A surgical strategy includes using the LGV graft. According to our reports, using LGV fulfilled the requirements for excellent vascular anastomosis and even allowed the dispensing of venous grafts. This is the largest case series in a single center of reconstruction of portal flow with direct anastomosis with the LGV without needing a vascular graft.
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Affiliation(s)
- Raquel Lima Sampaio
- From the Gastrointestinal Surgery Department, Walter Cantídio University Hospital, Fortaleza, CE, Brazil
| | - Gustavo Rego Coelho
- From the Gastrointestinal Surgery Department, Walter Cantídio University Hospital, Fortaleza, CE, Brazil
- Department of Liver Transplantation, Walter Cantídio University Hospital, Fortaleza, CE, Brazil
- Department of Liver Transplantation, São Carlos Hospital, Fortaleza, CE, Brazil
| | - Denissa Ferreira Gomes Mesquita
- From the Gastrointestinal Surgery Department, Walter Cantídio University Hospital, Fortaleza, CE, Brazil
- Department of Liver Transplantation, Walter Cantídio University Hospital, Fortaleza, CE, Brazil
- Department of Liver Transplantation, São Carlos Hospital, Fortaleza, CE, Brazil
| | - Carlos Eduardo Lopes Soares
- From the Gastrointestinal Surgery Department, Walter Cantídio University Hospital, Fortaleza, CE, Brazil
- Department of Liver Transplantation, Walter Cantídio University Hospital, Fortaleza, CE, Brazil
| | - José Huygens Parente Garcia
- From the Gastrointestinal Surgery Department, Walter Cantídio University Hospital, Fortaleza, CE, Brazil
- Department of Liver Transplantation, Walter Cantídio University Hospital, Fortaleza, CE, Brazil
- Department of Liver Transplantation, São Carlos Hospital, Fortaleza, CE, Brazil
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Kim SH, Moon DB, Kang WH, Jung DH, Lee SG. A surgical technique using the gastroepiploic vein for portal inflow restoration in living donor liver transplantation in a patient with diffuse portomesenteric thrombosis. Hepatobiliary Pancreat Dis Int 2023; 22:537-540. [PMID: 37005146 DOI: 10.1016/j.hbpd.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 03/16/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Sang-Hoon Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
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Alani M, Rowley M, Kang P, Chen S, Hirsch K, Seetharam A. Utility of Transjugular Intrahepatic Portosystemic Shunt Placement for Maintaining Portal Vein Patency in Candidates on Wait Lists Who Develop Thrombus. EXP CLIN TRANSPLANT 2019; 18:808-813. [PMID: 31830878 DOI: 10.6002/ect.2019.0153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Although no longer a contraindication to liver transplant, portal vein thrombosis may lead to longer operative time and complexities in venous reconstruction. Strategies to maintain preoperative patency include systemic anticoagulation and/or transjugular intrahepatic portosystemic shunt placement. The former may not be ideal in cirrhotic patients prone to luminal gastrointestinal tract bleeding, and factors that predict improvements in portal vein thrombosis with the latter have not been well defined. Our goal was to evaluate the effectiveness of transjugular intrahepatic portosystemic shunt placement as monotherapy to improve and/or resolve portal vein thrombosis in otherwise eligible liver transplant candidates with partial or complete portal vein thrombosis and to identify factors predicting success. MATERIALS AND METHODS We identified 30 patients from 2010 to 2015 who had transjugular intrahepatic portosystemic shunt placementfor primary indication to maintain portal vein patency. RESULTS The main portal vein was completely thrombosed in 5 of 30 (16.6%), nearly completely thrombosed in 9 of 30 (30%), and partially thrombosed in 16 patients (53.3%). Twenty-four patients (80%) had improvement and/or resolution of portal vein thrombosis after transjugular intrahepatic portosystemic shunt placement, with 18 of these (75%) having complete resolution. All 5 patients (20.8%) with complete thrombosis had improvement/resolution of portal vein thrombosis. Nine patients (30%) required hospitalization within 3 months for hepatic encephalopathy. There were 3 deaths (10%) not related to transjugular intrahepatic portosystemic shunt placement (10%). Nine patients underwent liver transplant after shunt placement (median 2.9 mo; range, 0.3-32 mo); all 9 received endto-end anastomosis without need for intraoperative thrombectomy. CONCLUSIONS Transjugular intrahepatic portosystemic shunt placement may be effective as monotherapy for maintaining or restoring portal vein patency in selected livertransplant candidates, even in those with complete portal vein thrombosis. Further studies are needed to define potential responders to this approach.
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Affiliation(s)
- Mustafa Alani
- From the Gastroenterology Department, St. Joseph's Hospital and Medical Center, Creighton University, Phoenix, Arizona, USA
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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: 62] [Impact Index Per Article: 12.4] [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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Bagheri Lankarani K, Honarvar B, Seif MA, Anushiravani A, Nikeghbalian S, Motazedian N, Janghorban P, Foroutanifard E, Akbari M, Malekhosseini SA. Outcome of Liver Transplant Patients With Intraoperative-Detected Portal Vein Thrombosis: A Retrospective Cohort Study in Shiraz, Iran. EXP CLIN TRANSPLANT 2019; 19:324-330. [PMID: 30995894 DOI: 10.6002/ect.2018.0295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES We aimed to determine outcomes and predictors of intraoperative-detected portal vein thrombosis in liver transplant recipients. MATERIALS AND METHODS We retrospectively analyzed 806 adult liver transplant recipients from Shiraz, Iran, to determine those with intraoperative-detected portal vein thrombosis. Patients with this complication were compared with age- and sex-matched patients without this complication. Background diseases, surgery parameters, hospital admission, reoperation, rethrombosis, acute rejection, and use of antico-agulants were assessed. Cox proportional hazards, logistic regression, and random classification forest and random survival forest plots were used for data analyses. RESULTS Mean age of patients was 44.7 ± 13.2 years. Patients with intraoperative-detected portal vein thrombosis (n = 91; 11.3%) had mortality ratio of 2.9 (range, 1.0-8.6) and 2-year survival of 78% versus 2-year survival rate of 92% in patients without this disease. Median time of survival in patients with this complication who died was 2 weeks versus 10 months in patients who died and did not have this complication. Random classification forest plots showed that high fasting blood sugar, autoimmune hepatitis, low prothrombin time, and cryptogenic cirrhosis were (in order) the main predictors of this complication. Random survival forest plots revealed that low prothrombin time, having intraoperative-detected portal vein thrombosis, Model for End Stage Liver Disease score, primary sclerosing cholangitis, diabetes mellitus, and hepatocellular carcinoma were (in order) the main predictors of death in liver transplant recipients. Low body mass index was associated with mortality in patients with intraoperative-detected portal vein thrombosis (by Cox proportional hazards). CONCLUSIONS One of every 9 liver transplant patients had intraoperative-detected portal vein thrombosis. Hazard of death was 2.9, and death occurred far earlier in patients with this complication. Improvements in diabetes mellitus care, prothrombin time, Model for End-Stage Liver Disease score, and body mass index may improve outcomes of these patients.
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Affiliation(s)
- Kamran Bagheri Lankarani
- From the Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
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Zanetto A, Rodriguez-Kastro KI, Germani G, Ferrarese A, Cillo U, Burra P, Senzolo M. Mortality in liver transplant recipients with portal vein thrombosis - an updated meta-analysis. Transpl Int 2018; 31:1318-1329. [DOI: 10.1111/tri.13353] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 04/20/2018] [Accepted: 09/13/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Alberto Zanetto
- Multivisceral Transplant Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
| | | | - Giacomo Germani
- Multivisceral Transplant Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
| | - Alberto Ferrarese
- Multivisceral Transplant Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit; Department of Surgery, Oncology and Gastroenterology; Padua University Hospital; Padua Italy
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Yu YD, Kim DS, Han JH, Yoon YI. Successful Treatment of a Patient With Diffuse Portosplenomesenteric Thrombosis Using a Pericholedochal Varix for Portal Flow Reconstruction During Deceased Donor Liver Transplantation: A Case Report. Transplant Proc 2018; 49:1202-1206. [PMID: 28583558 DOI: 10.1016/j.transproceed.2017.03.066] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Portal vein thrombosis remains a challenging issue in liver transplantation. When thrombectomy is not feasible due to diffuse portosplenomesenteric thrombosis, other modalities are adapted such as the use of a jump graft or portal tributaries or even multivisceral transplantation. For patients with diffuse thrombosis of the splanchnic venous system, a large pericholedochal varix can be a useful vessel for providing splanchnic blood flow to the graft and for relieving portal hypertension. We report our experience of successfully treating a patient with diffuse portosplenomesenteric thrombosis using a pericholedochal varix for portal flow reconstruction during deceased donor liver transplantation and eventually preventing unnecessary multivisceral transplantation. A 56-year-old man diagnosed with liver cirrhosis due to hepatitis B underwent deceased donor liver transplantation due to refractory ascites. Preoperative imaging revealed diffuse portosplenomesenteric thrombosis with large amount of ascites. During the operation, dissection of the main portal vein was not possible due to the development of multiple large pericholedochal varices and cavernous change of the main portal vein. After outflow reconstruction, portal inflow was restored by anastomosing the graft portal vein to a large pericholedochal varix. Postoperatively, although abdominal computed tomography scan showed stenosis of portal vein anastomosis site, liver function tests improved, and Doppler sonogram revealed no flow disturbance. During follow-up, the patient repeatedly developed hydrothorax and ascites. In addition, stenosis of the portal vein anastomosis and thrombosis of the portomesenteric system still remained. The patient underwent transhepatic portal vein stent insertion. After portal vein stent insertion, hydrothorax and ascites improved and the extent of thrombosis of the portomesenteric system decreased without anticoagulation therapy. In conclusion, enlarged pericholedochal varix in patients with totally obliterated splanchnic veins can be a source of useful inflow to restore portal flow and decrease the extent of thrombosis, thereby preventing unnecessary multivisceral transplantation.
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Affiliation(s)
- Y-D Yu
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Korea University Medical Center, Korea University Medical College, Seoul, Korea
| | - D-S Kim
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Korea University Medical Center, Korea University Medical College, Seoul, Korea.
| | - J-H Han
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Korea University Medical Center, Korea University Medical College, Seoul, Korea
| | - Y-I Yoon
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Korea University Medical Center, Korea University Medical College, Seoul, Korea
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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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Use of Left Gastric Vein as an Alternative for Portal Flow Reconstruction in Liver Transplantation. Case Rep Surg 2016; 2016:8289045. [PMID: 27595034 PMCID: PMC4993930 DOI: 10.1155/2016/8289045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/18/2016] [Indexed: 02/07/2023] Open
Abstract
Portal vein thrombosis is observed in up to 10% of liver transplant candidates, hindering execution of the procedure. A dilated gastric vein is an alternative to portal vein reconstruction and decompression of splanchnic bed. We present two cases of patients with portal cavernoma and dilated left gastric vein draining splanchnic bed who underwent liver transplantation. The vein was dissected and sectioned near the cardia; the proximal segment was ligated with suture and the distal segment was anastomosed to the donor portal vein. Gastroportal anastomosis is an excellent option for portal reconstruction in the presence of thrombosis or hypoplasia. It allows an adequate splanchnic drainage and direction of hepatotrophic factors to the graft.
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Mendoza-Sánchez F, Javier-Haro F, Mendoza-Medina DF, González-Ojeda A, Cortés-Lares JA, Fuentes-Orozco C. [Portal perfusion with right gastroepiploic vein flow in liver transplant]. CIR CIR 2016; 85:60-65. [PMID: 26769523 DOI: 10.1016/j.circir.2015.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 08/25/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Liver transplantation in patients with liver cirrhosis, portal vein thrombosis, and cavernous transformation of the portal vein, is a complex procedure with high possibility of liver graft dysfunction. It is performed in 2-19% of all liver transplants, and has a significantly high mortality rate in the post-operative period. Other procedures to maintain portal perfusion have been described, however there are no reports of liver graft perfusion using right gastroepiploic vein. CLINICAL CASE A 20 year-old female diagnosed with cryptogenic cirrhosis, with a Child-Pugh score of 7 points (class "B"), and MELD score of 14 points, with thrombosis and cavernous transformation of the portal vein, severe portal hypertension, splenomegaly, a history of upper gastrointestinal bleeding due to oesophageal varices, and left renal agenesis. The preoperative evaluation for liver transplantation was completed, and the right gastroepiploic vein of 1-cm diameter was observed draining to the infrahepatic inferior vena cava and right suprarenal vein. An orthotopic liver transplantation was performed from a non-living donor (deceased on January 30, 2005) using the Piggy-Back technique. Portal vein perfusion was maintained using the right gastroepiploic vein, and the outcome was satisfactory. The patient was discharged 13 days after surgery. CONCLUSIONS Liver transplantation was performed satisfactorily, obtaining an acceptable outcome. In this case, the portal perfusion had adequate blood flow through the right gastroepiploic vein.
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Affiliation(s)
- Federico Mendoza-Sánchez
- Unidad de Trasplantes, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Francisco Javier-Haro
- Departamento de Cirugía General, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Diego Federico Mendoza-Medina
- Unidad de Investigación en Epidemiología Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Alejandro González-Ojeda
- Unidad de Investigación en Epidemiología Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - José Antonio Cortés-Lares
- Unidad de Investigación en Epidemiología Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Clotilde Fuentes-Orozco
- Unidad de Investigación en Epidemiología Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México.
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Koh PS, Chan SC, Chok KSH, Sharr WW, Wong TCL, Sin SL, Lo CM. The friendly incidental portal vein thrombus in liver transplantation. Liver Transpl 2015; 21:944-52. [PMID: 25891227 DOI: 10.1002/lt.24149] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 04/05/2015] [Accepted: 04/12/2015] [Indexed: 12/12/2022]
Abstract
Improved outcomes have been shown in liver transplantation (LT) with portal vein thrombosis (PVT). However, PVT is still discovered incidentally during surgery despite careful preoperative imaging. Data are limited comparing the outcomes of incidental PVT with PVT diagnosed via preoperative imaging before LT. This study aims to compare the overall outcomes of patients with PVT. From 2008 to 2012, 369 patients had LT, and 58 patients with PVT were identified. They were divided into those with non-PVT (group 0; n = 311), preoperatively identified PVT (group 1; n = 28), and incidental PVT (group 2; n = 30). The demographics, characteristics, preoperative assessment, and postoperative outcomes were compared. A survival analysis was also performed. Baseline characteristics and preoperative evaluations of all 3 groups were comparable (P > 0.05) except for Model for End-Stage Liver Disease score, tumor status, platelet levels, and serum bilirubin. A multivariate analysis only showed a high serum bilirubin level to be a predictor of PVT (P = 0.004; odds ratio, 3.395; 95% confidence interval, 1.467-7.861). Postoperative outcomes were also comparable (P > 0.05). Compared to group 2, group 1 had more patients with a Yerdel classification of 3 or 4 with more extensive surgical intervention required (P = 0.02). The survival analysis in all 3 groups was comparable with 5-year survival rate of 87.4%, 84.6%, and 91.8% in group 0, 1, and 2, respectively (P = 0.66). In conclusion, recipients with PVT undergoing LT can have similar outcomes as the non-PVT patients even if PVTs were discovered incidentally. Discovery of incidental PVT only requires thrombectomy with no substantial change of treatment strategy, and the outcome is not adversely affected because most incidental PVTs are of a lower Yerdel grade. Preoperative imaging is useful to identify those with a higher Yerdel grade to allow planning of surgical strategy during transplantation.
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Affiliation(s)
- Peng Soon Koh
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - See Ching Chan
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Kenneth Siu-Ho Chok
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - William Wei Sharr
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Tiffany Cho-Lam Wong
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Sui Ling Sin
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Chung Mau Lo
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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Ponziani FR, Zocco MA, Senzolo M, Pompili M, Gasbarrini A, Avolio AW. Portal vein thrombosis and liver transplantation: implications for waiting list period, surgical approach, early and late follow-up. Transplant Rev (Orlando) 2014; 28:92-101. [PMID: 24582320 DOI: 10.1016/j.trre.2014.01.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 09/19/2013] [Accepted: 01/19/2014] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT) is a well-known and relatively common complication of liver cirrhosis. In the past, PVT was considered as a contraindication for liver transplantation (LT). To characterize prevalence, risk factors, perioperative management and outcome of PVT in the setting of LT, the English literature published between 1991 and 2011 was reviewed. Of 6807 articles, 280 were selected, and 39 experiences were analyzed in detail (methodology, type and duration of treatments, peri-operative management, strategy to avoid recurrence, strengths and weaknesses, Oxford evidence level, citations). 3/39 studies were prospective; 9/39 were based on prospectively recorded databases; no studies of 1, 2a, 3a level of evidence were present; 5/39 were recognized as level 2b, 23/39 as level 3b, and 8/39 as level 4. High complication rate has been reported with consequent effect on graft and patient survival. Overall, PVT presents today good results similar to those obtained in patients without PVT undergoing LT even if they require a higher transfusion number and a longer ICU/hospital stay. Reported cases were retrospectively stratified according to Yerdel classification. Grade 1-2 patients (76%) do well with eversion thromboendovenectomy, resection of damaged vein and porto-portal anastomosis. Results of patients with grade 3-4 (24%) are inferior, however data on outcome in this subsets are fragmented and do not allow a reliable analysis. Moreover, results obtained in grade 3-4 cases are better in transplant centers with large specific experience. The small number of reports suggests caution. The role of anticoagulant treatment is still debated. Although in cirrhotics with PVT LT remains a demanding procedure, PVT should not be considered a contraindication anymore.
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Affiliation(s)
- Francesca Romana Ponziani
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy.
| | - Maria Assunta Zocco
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Marco Senzolo
- Department of surgical, Oncological, and Gastroenterological Sciences University hospital of Padua, Padua, Italy
| | - Maurizio Pompili
- Department of Internal Medicine, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Alfonso Wolfango Avolio
- Department of Surgical Sciences, Division of General Surgery and Organs Transplantation, Catholic University, Agostino Gemelli Hospital, Rome, Italy
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13
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Liu SQ, Lei P, Cui XH, Lv Y, Li JH, Song YL, Zhao G. Sutureless anastomoses using magnetic rings in canine liver transplantation model. J Surg Res 2013; 185:923-33. [DOI: 10.1016/j.jss.2013.07.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 07/04/2013] [Accepted: 07/11/2013] [Indexed: 01/16/2023]
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D'Amico G, Tarantino G, Spaggiari M, Ballarin R, Serra V, Rumpianesi G, Montalti R, De Ruvo N, Cautero N, Begliomini B, Gerunda GE, Di Benedetto F. Multiple ways to manage portal thrombosis during liver transplantation: surgical techniques and outcomes. Transplant Proc 2013; 45:2692-9. [PMID: 24034026 DOI: 10.1016/j.transproceed.2013.07.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Portal vein thrombosis (PVT) is a well-recognized complication of chronic liver disease with a prevalence ranging from 1% to 16%. MATERIALS AND METHODS We performed a retrospective review of 447 consecutive patients who underwent liver transplantation (OLT) between October 2000 and December 2011 comparing 51 recipients with PVT (study group) with 399 without PVT (control group). The aim of this study was to determine the impact of pre-existent PVT on the surgical procedure, to identify specific preventable perioperative complications, and based on our studies and other works, to determine whether this group of patients are acceptable candidates for OLT. RESULTS Among the 51 patients with PVT, 44 showed partial and 7 complete thrombosis. In 47 cases, we performed a thromboendovenectomy. There were six anastomoses at the confluence of the superior mesenteric vein (SMV) and one, with a venous graft interposition. In four complete thrombosis recipients we performed an extra-anatomic by pass between the main trunk of the SMV and the donor portal vein. Compared with the control group, regarding preoperative characteristics, PVT patients were older at the time of transplantation (P = .001) and had a higher use of TIPS (P = .02). The operative characteristics showed a longer warm ischemia time in the PVT group (46.9 ± 22.5 vs 39.3 ± 15 min; P = .004). There were significant differences in postoperative evaluations, nor in the complication rates. Overall survivals at 10 years were similar: 61.7% versus 65.3%; (P = .9). CONCLUSION Although PVT was associated with greater operative complexity, it had no influence on postoperative complications or overall survival.
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Affiliation(s)
- G D'Amico
- Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
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Management of nonneoplastic portal vein thrombosis in the setting of liver transplantation: a systematic review. Transplantation 2013; 94:1145-53. [PMID: 23128996 DOI: 10.1097/tp.0b013e31826e8e53] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nonneoplastic portal vein thrombosis (PVT) is frequent in patients with cirrhosis who undergo liver transplantation (LT); however, data on its impact on outcome and strategies of management are sparse. METHODS A systematic review of the literature was performed by analyzing studies that report on PVT in LT recipients and were published between January 1986 and January 2012. RESULTS Of 25,753 liver transplants, 2004 were performed in patients with PVT (7.78%), and approximately half presented complete thrombosis. Thrombectomy/thromboendovenectomy was employed in 75% of patients; other techniques included venous graft interposition and portocaval hemitransposition. Overall, the presence of PVT significantly increased 30-day (10.5%) and 1-year (18.8%) post-LT mortality when compared to patients without PVT (7.7% and 15.4%, respectively). However, only complete PVT accounted for this increased mortality. Rethrombosis occurred in up to 13% of patients with complete PVT and in whom no preventative strategies were used, and was associated with increased morbidity and mortality. CONCLUSIONS PVT is common in patients with cirrhosis undergoing LT, and it affects survival when it is complete, at least in the short term after transplant. Therefore, screening for this condition is essential, alongside adequate treatment strategies to attempt repermeation of the PV and prevent thrombosis extension.
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16
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Rodriguez-Castro KI, Simioni P, Burra P, Senzolo M. Anticoagulation for the treatment of thrombotic complications in patients with cirrhosis. Liver Int 2012; 32:1465-76. [PMID: 22734713 DOI: 10.1111/j.1478-3231.2012.02839.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 05/22/2012] [Indexed: 02/13/2023]
Abstract
Cirrhotic patients can develop thrombotic complications, which in this group of patients occur with a greater frequency than in the general population. Portal vein thrombosis (PVT) is the most common thrombotic phenomenon, although deep venous thrombosis and pulmonary embolism can also occur. Risk factors for thrombosis include inherited and acquired deficiency of factors involved in anticoagulation mechanisms, venous stasis of the portal vein owing to architectural derangement of the liver and possibly local factors related to the endothelium. Clinical manifestations of PVT range from asymptomatic disease to a life-threatening complication, and although it is no longer considered an absolute contraindication for liver transplant, its presence may require challenging surgical techniques, which entail greater morbidity. Anticoagulation therapy is henceforth an important strategy to treat cirrhotic patients with PVT, although experience in this group of patients is limited. Vitamin K antagonists and low-molecular-weight heparin have been used successfully, achieving recanalization of the thrombosed vessel in patients with cirrhosis; however, the precise drug regimen management and monitoring has not be fully explored in this group of patients.
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Affiliation(s)
- Kryssia I Rodriguez-Castro
- Multivisceral Transplant Unit, Department of Surgical, Oncological, and Gastroenterological Sciences, Padua University Hospital, Padua, Italy
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Caval inflow to the graft for liver transplantation in patients with diffuse portal vein thrombosis: a 12-year experience. Ann Surg 2012; 254:1008-16. [PMID: 21869678 DOI: 10.1097/sla.0b013e31822d7894] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To analyze the short- and long-term results of cavoportal anastomosis (CPA) and renoportal anastomosis (RPA) in 20 consecutive liver transplantation (LT) candidates with diffuse portal vein thrombosis (PVT). SUMMARY BACKGROUND DATA Caval inflow to the graft (CIG) by CPA or RPA has been the most commonly used salvage technique to overcome the absolute contraindication for LT in case of diffuse PVT. METHODS From 1996 to 2009, 3 patients (15%) underwent CPA and 17 patients (85%) had an RPA during LT. In addition to routine follow-up, patients were specifically evaluated for signs of portal hypertension (PHT) and for patency of the anastomoses. The follow-up ranged from 3 months to 12 years (median of 4.5 years). RESULTS : Caval inflow to the graft was feasible in all attempted cases. In the short term (<6 months), 35% of patients had residual PHT-related complications (massive ascites and variceal bleeding). These resolved spontaneously or with endoscopic management. Three deaths occurred; none was related to PHT or shunt thrombosis. In the long term (>6 months), 1 death occurred because of recurrent variceal bleeding after RPA thrombosis. At last follow-up, all living patients [n = 13 (65%)] had normal liver function, no signs of PHT and patent anastomoses. There were no retransplantations. Graft and patient survival at 1, 3, and 5 years were 83%, 75%, and 60%, respectively. CONCLUSIONS Caval inflow to the graft is an efficacious salvage technique with satisfactory long-term results, considering the spontaneous outcome in patients denied LT because of diffuse PVT. Adequate preoperative management of PHT and its associated complications is vital in obtaining good results. In the long term, residual PHT resolves and the liver function returns to normal.
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Kim JD, Choi DL, Han YS. An early single-center experience of portal vein thrombosis in living donor liver transplantation: clinical feature, management and outcome. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 81:35-42. [PMID: 22066098 PMCID: PMC3204558 DOI: 10.4174/jkss.2011.81.1.35] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 05/17/2011] [Indexed: 12/19/2022]
Abstract
PURPOSE Portal vein thrombosis (PVT) has been considered a relative contraindication for living donor liver transplantation (LDLT). However, it is no longer a contraindication of LDLT due to improvement in surgical techniques and approaches to PVT. The aim of this study was to assess the impact of PVT on outcomes in LDLT patients. METHODS We retrospectively analyzed the data from 97 adult patients undergoing LDLT in our center from July 2008 to June 2010. Intraoperative findings and preoperative imaging results were reviewed for PVT grading (Yerdel grading). We analyzed the technical aspects and comparisons of risk factors, perioperative variables, and survivals between patients with and without PVT based on the grades. RESULTS In the 97 LDLT patients, 18 patients were confirmed to have PVT (18.5%) including grade I cases (n = 8), grade II (n = 7), and grade III (n = 3). Prior treatment of portal hypertension was found to be an independent risk factor for PVT (P = 0.001). The comparisons between PVT and no PVT groups showed no significant difference in intraoperative and postoperative variables except for postoperative bleeding (P = 0.036). The short-term portal vein patency, in-hospital mortality and survival rates were not significantly different between the PVT and control groups. CONCLUSION The outcomes are similar to non-PVT group in terms of in-hospital mortality, survival rates, and postoperative complications. Therefore, our study suggests that PVT cannot be considered to be a contraindication for LDLT and LDLT could be undertaken without increased morbidity and mortality in patients with PVT, in spite of operative complexity.
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Affiliation(s)
- Joo Dong Kim
- Division of Hepatobiliary and Transplantation Surgery, Department of Surgery, Catholic University of Daegu School of Medicine, Daegu, Korea
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19
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Portal vein thrombosis and liver transplantation: evolution during 10 years of experience at the University of Bologna. Ann Surg 2011; 253:378-84. [PMID: 21183851 DOI: 10.1097/sla.0b013e318206818b] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the evolution of liver transplantation (LT) in cases with partial and total portal vein thrombosis (PVT). BACKGROUND Portal vein thrombosis and in particular total PVT are still surgically demanding conditions, which can exclude patients from LT or increase the postoperative complications after LT. METHODS We reviewed our 10-year experience (first era 1998–2002 and second era 2003–2008), comparing the outcome of patients with PVT to a group without PVT. RESULTS Among 889 LTs, we intraoperatively diagnosed 91 PVTs (10.2%):51 partial PVTs (56%) and 40 total PVTs (44%). The rate of complete PVTs increased from the first to the second era (2.2% vs. 6.7%, P < 0.005). Partial PVTs were mainly treated with thrombectomy while complete PVTs were managed with thrombectomy in 26 cases (63%), jumping graft in 6 (15%), portocaval hemitransposition in 6 (15%), and anastomosis to varix in 3 (7%). Among cases of PVT and no-PVT, the postoperative mortality was comparable (6.6% vs. 5.8%), as were the 1- and 5-year patient survival rates (85% and 68% PVT vs. 86% and 73% non-PVT). The postoperative outcome was similar in the PVT group between patients with partial and complete PVT, but in this last group, patient survival differed significantly between the 1st and 2nd era (57% vs. 89% at 1 year, P < 0.05). CONCLUSIONS Liver transplantation offers good survival in patients with partial PVT but also in selected cases with total PVT, where surgical innovation has improved the results.
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Kim BW. Liver Transplantation in Liver Cirrhosis Patients Accompanied by Portal Vein Thrombosis. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2011; 15:78-82. [PMID: 26421021 PMCID: PMC4582549 DOI: 10.14701/kjhbps.2011.15.2.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Benign portal vein thrombosis (PVT) is a challenging complication of an otherwise successful liver transplantation. PVT is caused by various conditions and results in pathologic hemodynamics of hepatofugal diversion of porto-mesenteric blood flow. Thus, adequate restoration of portal blood flow to the liver graft is a major concern when trying to achieve successful liver transplantation in patients with PVT. This letter describes the surgical view point of PVT in liver transplantation.
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Affiliation(s)
- Bong-Wan Kim
- Department of Surgery, Ajou University School of Medicine, Korea
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21
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Qi X, Bai M, Yang Z, Yuan S, Zhang C, Han G, Fan D. Occlusive portal vein thrombosis as a new marker of decompensated cirrhosis. Med Hypotheses 2011; 76:522-6. [PMID: 21216538 DOI: 10.1016/j.mehy.2010.12.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 12/01/2010] [Accepted: 12/08/2010] [Indexed: 02/07/2023]
Abstract
Natural history of liver cirrhosis is divided into compensated and decompensated stage. Traditionally, the markers of decompensated cirrhosis include ascites, variceal hemorrhage, hepatic encephalopathy and jaundice. The clinical importance of portal vein thrombosis (PVT) is increasingly recognized in patients with liver cirrhosis. The presence of PVT is not only an independent predictor of failure to control active variceal bleeding and prevent variceal rebleeding, but also significantly associated with increased mortality in patients with liver cirrhosis. Besides, it greatly influences the technical success and outcome of endovascular interventional treatment and liver transplantation for liver cirrhosis and its secondary portal hypertension. Thus, we hypothesize that PVT should be regarded as a critical marker of decompensated cirrhosis, whether clinical events such as the development of ascites, encephalopathy, and variceal bleeding occur or not. Our hypothesis adds PVT into the definition of decompensated cirrhosis and reminds clinicians and investigators that PVT plays a vital role in natural history of liver cirrhosis. Further, it is essential to construct a new system of preventing and treating liver cirrhosis in the presence of PVT.
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Affiliation(s)
- Xingshun Qi
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
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22
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Sharma R, Kashyap R, Jain A, Safadjou S, Graham M, Dwivedi AK, Orloff M. Surgical complications following liver transplantation in patients with portal vein thrombosis--a single-center perspective. J Gastrointest Surg 2010; 14:520-7. [PMID: 19960270 DOI: 10.1007/s11605-009-1111-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Accepted: 11/10/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Portal vein thrombosis (PVT) was once considered a contraindication for liver transplantation (LTx) because of technical difficulties. Though no longer a contraindication, it remains a risk factor. AIM A study of surgical complications following LTx in patients with and without PVT. PATIENTS AND METHODS A retrospective review of 1,171 consecutive patients who underwent LTx between June 1995 and June 2007 was performed, and 78 recipients with PVT (study group) were compared with a stratified random sample of 78 contemporous recipients without PVT (control group) for postoperative complications. Both groups were comparable with respect to age, sex, race, and other confounding variables. RESULTS The rate of primary nonfunction (PNF) in the study and control groups was 9.0% and 1.3%, (p = 0.063), while that of retransplantation was 17.9% and 7.7% (p = 0.055), respectively. The mean donor risk index (DRI) among the patients with and without PNF in the study group was 2.58 +/- 0.44 and 2.08 +/- 0.42, respectively (p = 0.014). A significantly higher number of packed red blood cells and fresh frozen plasma transfusions were observed in study group compared to controls (p = 0.012, 0.007, respectively). CONCLUSION A higher rate of PNF was related to the complexity of the surgical procedure and the use of donor livers with a high DRI. Higher rates of PNF eventually led to a higher rate of retransplant. A strategy of offering donor livers with a low DRI might be helpful in decreasing the rate of PNF. Further, a PV interposition graft in difficult cases instead of thrombectomy could lead to a lower rethrombosis rate.
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Affiliation(s)
- Rajeev Sharma
- Division of Solid Organ Transplantation, Department of Surgery, University of Rochester Medical Center, Box SURG, Rochester, NY 14620, USA.
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Shi Z, Yan L, Zhao J, Li B, Wen T, Xu M, Wang W, Chen Z, Yang J. Prevention and treatment of rethrombosis after liver transplantation with an implantable pump of the portal vein. Liver Transpl 2010; 16:324-31. [PMID: 20209592 DOI: 10.1002/lt.21988] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Implantable pumps have been used to prevent deep vein thrombosis and other diseases. In this article, we report for the first time the prevention and treatment of rethrombosis of the portal vein in liver transplantation with an implantable pump of the portal vein. Four hundred four orthotopic liver transplantation cases were retrospectively reviewed and divided into 3 groups: portal vein thrombosis (PVT) patients with an implantable pump (n = 28), PVT patients without an implantable pump (n = 20), and patients without preexisting PVT (n = 356). The following parameters for the 3 groups of patients were calculated and compared: (1) preoperative parameters, including baseline data of the donors and recipients and times of graft ischemia; (2) intraoperative and postoperative parameters, including surgery time, red blood cell and plasma transfusion, platelet concentrate transfusion, bleeding and primary graft malfunction, and duration of the hospital and intensive care unit stays; and (3) follow-up information for the patency of the portal vein, rethrombosis rate, stenosis and reoperation (relaparotomy or retransplantation), in-hospital mortality, and actuarial 1-year survival rate. Among the 3 groups of recipients, no significant differences were detected in preoperative and intraoperative parameters. However, compared to PVT patients without an implantable pump, PVT patients with an implantable pump showed remarkable reductions in their postoperative hospital stay, rethrombosis, reoperation rate, and in-hospital mortality. An implantable pump of the portal vein in liver transplantation patients can prevent and facilitate the treatment of portal vein rethrombosis and is associated with a reduction of in-hospital mortality.
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Affiliation(s)
- Zhengrong Shi
- Liver Transplantation Division, Department of Surgery, West China Hospital, Sichuan University, Chengdu, China
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24
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Doenecke A, Tsui TY, Zuelke C, Scherer MN, Schnitzbauer AA, Schlitt HJ, Obed A. Pre-existent portal vein thrombosis in liver transplantation: influence of pre-operative disease severity. Clin Transplant 2009; 24:48-55. [PMID: 19236435 DOI: 10.1111/j.1399-0012.2009.00977.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Portal vein thrombosis (PVT) is a surgical challenge in liver transplantation (LTx). In contrast to LTx in decompensated liver disease, which are associated with a higher morbidity and mortality, PVT influence on outcome is still under debate. To evaluate this influence at different stages of liver decompensation, we compared the outcome of patients suffering from PVT to patients with patent portal vein within different score ranges. METHODS We included 193 LTx (24 with PVT) in our study, transplanted between 2004 and 2007 at our institution. Patients were divided into four Model of End-Stage Liver Disease (MELD) score groups, and outcome was compared between PVT- and non-PVT patients. RESULTS In non-decompensated liver disease (MELD <15), we found a significantly decreased survival in patients suffering from PVT (one-yr survival 57% vs. 89%). By contrast, MELD score >15 (decompensated liver disease) leads to an equal or even better survival in PVT-patients compared with patients without PVT (one-yr survival 91% vs.75%), with an only slightly increased morbidity. CONCLUSION Outcome in patients with PVT seems to be dependent on pre-operative disease severity. In contrast to compensated liver disease, no influence of PVT on outcome could be found in decompensated liver disease, and should therefore not be considered as a contraindication in LTx.
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Affiliation(s)
- A Doenecke
- Klinik und Poliklinik für Chirurgie, Uniklinikum Regensburg, Regensburg, Germany.
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Paraumbilical collateral veins on MRI as possible protection against portal venous thrombosis in candidates for liver transplantation. ACTA ACUST UNITED AC 2008; 33:536-41. [PMID: 17924159 DOI: 10.1007/s00261-007-9333-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We retrospectively evaluate the potential protective influence of patent paraumblical vein (PUV) collaterals against portal vein (PV) thrombosis and reduced PV diameter in candidates for orthotopic liver transplant (OLT) METHODS: Dynamic 3D contrast-enhanced MRI at 1.5T was obtained in 309 patients with cirrhosis without evidence of malignancy. All MR studies were reviewed by one reader for PUV collaterals, PV thrombosis and PV diameter. Statistical analysis was performed by Fisher exact tests; 50 selected studies were reviewed independently by two additional readers to determine interobserver agreement via intraclass correlation coefficient (ICC). RESULTS Patent PUV was noted in 119 of 309 patients (38.5%). Mean PV diameter was 13.4 +/- 3.0 mm in patients with PUV compared with 11.3 +/- 3.6 mm without PUV (P < 0.01). Main PV thrombosis was present in 13 of 309 patients (4.2%) and significantly more frequent in those without PUV than with PUV (6.3% vs. 0.8%, P < 0.05). ICC indicated almost perfect agreement among three readers for presence of PUV collaterals (ICC = 0.91) and PV thrombosis (ICC = 0.96). CONCLUSION Our results suggest that patients with patent PUV appear less likely to develop main PV thrombosis or small PV diameter, suggesting a protective effect of PUV on PV patency.
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Sotiropoulos GC, Radtke A, Schmitz KJ, Molmenti EP, Schroeder T, Saner FH, Baba HA, Fouzas I, Broelsch CE, Malagó M, Lang H. Liver transplantation in the setting of hepatocellular carcinoma and portal vein thrombosis: a challenging dilemma? Dig Dis Sci 2008; 53:1994-9. [PMID: 18080191 DOI: 10.1007/s10620-007-0099-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Accepted: 10/27/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND Portal vein thrombosis (PVT) represents a potentially unfavorable prognostic factor in liver transplantation (LT) for hepatocellular carcinoma (HCC). However, it is frequently difficult to establish preoperatively whether the thrombus is associated with tumor invasion or with stagnant flow. The purpose of this study was to further address this controversial issue. PATIENTS AND METHODS We evaluated 12 consecutive patients who underwent liver transplantation for HCC in the setting of PVT. RESULTS The origin of PVT in HCC patients could be accurately evaluated in 58% of the patients. Forty-two percent of patients had no evident portal vein invasion and only 17% of cases had tumor thrombi. One-third of patients experienced tumor recurrence within the first posttransplant year, and one-third of patients became long-term survivors (median survival of 36 months) with no evidence of tumor recurrence. One-year survival was 92%. Nine patients are currently alive after a median follow-up period of 25 months. CONCLUSIONS PVT in the setting of HCC is characterized by poor patient outcome. However, a respectable number of instances are not accurately evaluated preoperatively, making the decision to exclude these patients from LT sometimes a challenging dilemma.
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Affiliation(s)
- Georgios C Sotiropoulos
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, Essen 45122, Germany.
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Cho JY, Suh KS, Shin WY, Lee HW, Yi NJ, Lee KU. Thrombosis Confined to the Portal Vein Is Not a Contraindication for Living Donor Liver Transplantation. World J Surg 2008; 32:1731-7. [DOI: 10.1007/s00268-008-9651-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Adani GL, Baccarani U, Risaliti A, Sponza M, Gasparini D, Bresadola F, de Anna D, Bresadola V. Percutaneous Transhepatic Portography for the Treatment of Early Portal Vein Thrombosis After Surgery. Cardiovasc Intervent Radiol 2007; 30:1222-6. [PMID: 17573552 DOI: 10.1007/s00270-007-9056-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Revised: 03/16/2007] [Accepted: 04/01/2007] [Indexed: 02/07/2023]
Abstract
We treated three cases of early portal vein thrombosis (PVT) by minimally invasive percutaneous transhepatic portography. All patients developed PVT within 30 days of major hepatic surgery (one case each of orthotopic liver transplantation, splenectomy in a previous liver transplant recipient, and right extended hepatectomy with resection and reconstruction of the left branch of the portal vein for tumor infiltration). In all cases minimally invasive percutaneous transhepatic portography was adopted to treat this complication by mechanical fragmentation and pharmacological lysis of the thrombus. A vascular stent was also positioned in the two cases in which the thrombosis was related to a surgical technical problem. Mechanical fragmentation of the thrombus with contemporaneous local urokinase administration resulted in complete removal of the clot and allowed restoration of normal blood flow to the liver after a median follow-up of 37 months. PVT is an uncommon but severe complication after major surgery or liver transplantation. Surgical thrombectomy, with or without reconstruction of the portal vein, and retransplantation are characterized by important surgical morbidity and mortality. Based on our experience, minimally invasive percutaneous transhepatic portography should be considered an option toward successful recanalization of early PVT after major liver surgery including transplantation. Balloon dilatation and placement of a vascular stent could help to decrease the risk of recurrent thrombosis when a defective surgical technique is the reason for the thrombosis.
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Affiliation(s)
- Gian Luigi Adani
- Department of Surgery & Transplantation, University Hospital of Udine, Via Colugna 50, 33100 Udine, Italy.
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29
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Selvaggi G, Weppler D, Nishida S, Moon J, Levi D, Kato T, Tzakis AG. Ten-year experience in porto-caval hemitransposition for liver transplantation in the presence of portal vein thrombosis. Am J Transplant 2007; 7:454-60. [PMID: 17229075 DOI: 10.1111/j.1600-6143.2006.01649.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Porto-caval hemitransposition (PCH) in liver transplantation allows revascularization of the liver when the porto-mesenteric axis is thrombosed. We, here, review our experience over an 11-year period. A total of 23 patients underwent liver transplantation using PCH. Immunosuppression was based on tacrolimus, with sirolimus used in case of renal insufficiency. Most common diagnoses were hepatitis C, Laennec's, Budd-Chiari and cryptogenic cirrhosis. Six patients needed splenectomy prior to transplant, 5 during transplant, 1 post-transplant, 11 had no splenectomy. Overall survival was 60% at 1 year and 38% at 3 years, with 10 of 23 patients currently alive and the longest survivor at 9.3 years. Most common cause of death was sepsis/multisystem organ failure, followed by pulmonary embolism. A total of 7/23 patients experienced post-operative gastrointestinal bleeding episodes, 6/23 patients developed thrombosis of the vena cava (median 162 days post-op). Post-operative ascites was noted in almost all patients. Renal dysfunction was commonly seen even after the first month post-transplant. PCH offers a feasible option for liver transplantation in those patients with complex thrombosis of the mesenteric and portal circulation.
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Affiliation(s)
- G Selvaggi
- Division of Liver and GI Transplantation, University of Miami Miller School of Medicine, Miami, Florida, USA.
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30
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Senzolo M, Burra P, Cholongitas E, Lodato F, Marelli L, Manousou P, Patch D, Sturniolo GC, Burroughs AK. The transjugular route: the key hole to the liver world. Dig Liver Dis 2007; 39:105-16. [PMID: 17196894 DOI: 10.1016/j.dld.2006.06.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Revised: 06/20/2006] [Accepted: 06/27/2006] [Indexed: 02/07/2023]
Abstract
Portal hypertensive complications are major causes of morbidity and mortality in patients with liver cirrhosis. The advent of the transjugular route with its minimal access allows non-surgical management of portal hypertension, therapy of venous complications of liver transplantation, monitoring of therapy for portal hypertension, hepatic venous pressure gradient and is also the major route to treat hepatic venous obstruction syndromes. In addition, the transjugular route is a safe route to perform a liver biopsy (transjugular liver biopsy) and allows retrograde evaluation of the portal vein. All these procedures can be combined in the same session. These hepatic interventional radiological skills should be incorporated into the expertise of the liver team in specialised hepatological centres, particularly in liver transplant centres as they are especially useful in improving outcomes of cirrhotic patients on the liver transplantation waiting list. A limitation in achieving this goal, could be the number of experienced radiologists, but hepatologists can be trained, at least for the most simple procedures (transjugular liver biopsy and hepatic venous pressure gradient). This would allow wider applicability and use of these diagnostic and therapeutic techniques, all through a 2 mm hole in the neck--the key hole to the liver world.
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Affiliation(s)
- M Senzolo
- Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital, London, Pond Street, London NW3 2QG, UK
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31
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Paskonis M, Jurgaitis J, Mehrabi A, Kashfi A, Fonouni H, Strupas K, Büchler MW, Kraus TW. Surgical strategies for liver transplantation in the case of portal vein thrombosis--current role of cavoportal hemitransposition and renoportal anastomosis. Clin Transplant 2007; 20:551-62. [PMID: 16968480 DOI: 10.1111/j.1399-0012.2006.00560.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Portal vein thrombosis (PVT), a common complication of end stage liver disease, is no longer considered a definite contraindication for liver transplantation (LTx). The clinical decision to perform an LTx in the case of PVT depends on the degree of PVT and the experience of the surgeon. Eversion thromboendovenectomy was suggested by most authors as the surgical technique of choice for PVT grade 1, 2, and 3. If PVT obstructs more extended parts of the porto-mesenteric venous circulation, surgical options would include different types of venous jump graft reconstructions or arterialization of the portal vein. Combined liver and small bowel transplantation is another possible alternative. Cavoportal hemitransposition (CPHT) and renoportal anastomosis (RPA) were recently particularly advocated as creative surgical strategies in case of diffuse PVT. In this work, we focus on CPHT and RPA surgical techniques during LTx, which attempts to secure the portal flow to the liver graft in case of pre-existent diffuse PVT. We provide a review of all reported clinical experience at international clinical centers using these techniques. According to our meta-analysis a total of 15 studies were published on this topic between 1996 and 2005. In summary, a total of 56 orthotopic LTx have been performed in 53 patients (28 men, 25 women) combined with either CPHT or RPA, for the purpose of providing the donor graft with adequate inflow. Mean age was 44 yr including two patients who were infants, with the youngest recipient being two yr old. Main indications for LTx were liver cirrhosis caused by viral hepatitis, alcoholic cirrhosis and cryptogenic cirrhosis. CPHT was performed in 46 cases, and RPA in 10 cases. Thirty-five of 53 patients (66%) had surgery previous to LTx. Of these, 13 patients (37%) [corrected] presented with a history of other previous surgical procedures for decompression of portal hypertension or treatment of associated complications (portocaval shunts, splenectomy, etc). Ascites, renal dysfunction, lower extremity and torso edema and variceal bleeding were dominant post-operative complications after CPHT or RPA noted in 22 cases (41.5%), 18 cases (34%), 17 cases (32%) and 13 cases (24.5%) respectively. Patients' follow-up ranged from two to 48 months. Thirty nine of 53 patients [corrected] (74%) survived [corrected] and 14 patients died (26%) [corrected] during the course of observation. Based on the literature, we conclude that the ideal technique to overcome PVT during LTx is still controversial. Short-term follow-up results of both methods are promising, however, long-term results are unknown at present. Furthermore, clinical follow-up and basic experimental work is required to evaluate the influence of systemic venous inflow to the liver graft with respect to long-term liver function and liver regeneration.
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Affiliation(s)
- Marius Paskonis
- Department of Abdominal Surgery, Vilnius University Hospital 'Santariskiu klinikos', University of Vilnius, Vilnius, Lithuania
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32
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Egawa H, Tanaka K, Kasahara M, Takada Y, Oike F, Ogawa K, Sakamoto S, Kozaki K, Taira K, Ito T. Single center experience of 39 patients with preoperative portal vein thrombosis among 404 adult living donor liver transplantations. Liver Transpl 2006; 12:1512-8. [PMID: 17004256 DOI: 10.1002/lt.20777] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Living donor liver transplantation (LDLT) for patients with portal vein thrombosis (PVT) involves technical difficulty. The aim of this research was to analyze their preoperative diagnosis of PVT, operative procedures, and postoperative courses of patients with preoperative PVT. Thirty-nine patients of 404 adult patients (9.7%) undergoing LDLT in our hospital from 1996 June to 2004 December had PVT at their transplantation. Twenty-nine patients had intractable ascites, 21 had gastrointestinal bleeding, and 18 had encephalopathy. The thrombus was located in the portal trunk in 23, in the portal trunk and superior mesenteric vein (SMV) in 7, and developed into the SMV and the splenic vein in 8. The occlusive grade was partial in 29, and complete in 10 patients. The thrombus was removed by a simple technique, and eversion and/or incision technique, or total removal of the portal vein (PV). The PV was reconstructed with the thrombectomized native PV, with an interposed vein graft, or porto-caval hemitransposition. Advanced PVT had a significant impact on blood loss and hospital mortality. Three out of 10 patients with residual PVT required radiological and/or surgical intervention after transplantation. In conclusion, thorough planning is essential for a successful LDLT outcome for patients with preexisting PVT.
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Affiliation(s)
- Hiroto Egawa
- Organ Transplant Unit, Department of Transplant Surgery, Kyoto University Hospital, Kyoto, Japan.
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Bauer J, Johnson S, Durham J, Ludkowski M, Trotter J, Bak T, Wachs M. The role of TIPS for portal vein patency in liver transplant patients with portal vein thrombosis. Liver Transpl 2006; 12:1544-51. [PMID: 17004250 DOI: 10.1002/lt.20869] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The purpose of this research was to study the efficacy and outcomes of transjugular intrahepatic shunt (TIPS) in end-stage liver disease (ESLD) patients with portal vein thrombosis (PVT) eligible for orthotopic liver transplant. Nine consecutive patients with PVT underwent TIPS as a nonemergent elective outpatient procedure. The primary indication for TIPS was to maintain portal vein patency for optimal surgical outcome. Eight patients underwent contrast enhanced computed tomography (CT) and 1 magnetic resonance imaging diagnosing PVT. Shunt creation was determined by available targets at the time of TIPS and by prior imaging. Patients were followed with portography, ultrasound, CT, or magnetic resonance imaging, and the luminal occlusion was estimated before and after TIPS. Primary endpoints were transplantation, removal from the transplant list, or death. Stabilization, improvement, or complete resolution of thrombosis was considered successful therapy. Failures included propagation of thrombosis or vessel occlusion, and poor surgical anatomy due to PVT. Of 9 patients with PVT, TIPS was successfully placed in all patients without complication or TIPS-related mortality. Eight of 9 patients (88.8%) had improvement at follow-up. One patient failed therapy and re-thrombosed. Two patients (22.2%) were transplanted without complication and had no PVT at the time of transplant. Eight of 9 patients were listed for transplant at the time of their TIPS. Eight of 9 PVTs were nonocclusive. Four of 9 patients (44%) had evidence of cavernous transformation. Two patients expired during follow-up 42 and 44 months after TIPS. Three patients remain on the transplant list. One patient has not been listed due to nonprogression of disease. One patient has been removed from the transplant list because of comorbid disease. In conclusion, TIPS is safe and effective in patients with PVT and ESLD requiring transplant. Patients can be successfully transplanted with optimal surgical anatomy.
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Affiliation(s)
- Jason Bauer
- Department of Radiology, Division of Interventional Radiology, University of Colorado Health Sciences Center, Denver, CO 80262, USA
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Karakayali H, Boyvat F, Coskun M, Isiklar I, Sözen H, Filik L, Yilmaz U, Gür G, Haberal M. Venous complications after orthotopic liver transplantation. Transplant Proc 2006; 38:604-6. [PMID: 16549187 DOI: 10.1016/j.transproceed.2006.01.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We report venous complications, including portal vein and hepatic vein stenoses, that required interventional radiological treatment in three pediatric and two adult living related liver transplant recipients. Between April 2001 and April 2005, 81 liver transplantations were performed at our hospital. Sixty-two grafts were from living donors. During follow-up, three portal vein stenoses were identified in three pediatric recipients, and two hepatic vein stenoses in two adult patients. In the children, two had received left lateral segment grafts, and one had received a right lobe graft from two mothers and one father, respectively. The etiologies of liver failure were Alagille syndrome, biliary atresia, and fulminant Wilson's disease. Portal vein stenoses were identified at 8, 11, and 12 months after transplantation; all three patients underwent percutaneous transhepatic portal venous angioplasty with a success rate of 100%. The mean follow-up was 102 days; no recurrence has occurred. In contrast, hepatic venous stenoses were diagnosed in two adult recipients. One of them was a 24-year-old woman with autoimmune hepatitis and the other a 43-year-old man with cryptogenic cirrhosis. Hepatic vein stenoses were diagnosed at 3 and 4 months after transplantation. Both hepatic vein stenoses were dilated with balloon angioplasties via the transjugular route. Venous complications identified by Doppler ultrasonography were confirmed by computerized tomographic angiography. Angioplasty represents an effective and safe alternative to reconstructive surgery in the treatment of venous complications after liver transplantation.
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Affiliation(s)
- H Karakayali
- Department of General Surgery, Başkent University, Faculty of Medicine, Ankara, Turkey
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35
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Lipshutz GS, Patel S, Hiatt JR, Yersiz H, Farmer DG, McDiarmid SV, Ghobrial RM, Busuttil RW. Portocaval hemitransposition in pediatric liver transplant recipients: a single-center experience. Liver Transpl 2006; 12:1097-103. [PMID: 16799947 DOI: 10.1002/lt.20770] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Few studies have reported a series of patients who have undergone portocaval hemitransposition at the time of orthotopic liver transplantation (OLT). Furthermore, no series report the outcome of pediatric patients who required the procedure. This work analyzes the experience with portocaval hemitransposition in the pediatric liver transplant population at a single center since the initial description of the procedure. We carried out a retrospective analysis of all pediatric liver transplants performed in our institution during the 8-year period from January 1, 1997, to December 31, 2004. Of 320 pediatric patients who received OLT during the study period, 7 underwent portocaval hemitransposition (2.2%). Five of the patients had biliary atresia. Four grafts were whole cadaveric livers, while the remaining 4 were left lateral segments from either in situ cadaveric split (n = 3) or living donation (n = 1). One patient received a whole cadaveric allograft and was retransplanted with a segment 2/3 graft; in both cases portocaval hemitransposition was utilized. Average warm ischemia time was 54 +/- 16 minutes. Three patients had primary nonfunction of the allograft; 2 were retransplanted with successful outcome, and the remaining patient died before retransplantation. Another patient died from recurrent disease. Four of 7 are long-term survivors and demonstrate good liver function as long as 8 years posttransplant. In conclusions, long-term survival is possible following OLT with portocaval hemitransposition in pediatric patients. However, rates of primary graft nonfunction can be high. Appropriate selection of recipient and type of donor graft are essential for good outcomes. Portocaval hemitransposition should be used cautiously and as a last resort to establish portovenous inflow.
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Affiliation(s)
- Gerald S Lipshutz
- Dumont-UCLA Liver Transplant Center, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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36
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Senzolo M, Tibbals J, Cholongitas E, Triantos CK, Burroughs AK, Patch D. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation. Aliment Pharmacol Ther 2006; 23:767-75. [PMID: 16556179 DOI: 10.1111/j.1365-2036.2006.02820.x] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Treatment options for patients with portal vein thrombosis are limited. AIM To evaluate the feasibility and efficacy of transjugular intrahepatic portosystemic shunt for portal vein thrombosis with/without cavernomatous transformation. METHODS A survey of such patients, referred for transjugular intrahepatic portosystemic shunt between 1994 and 2005, was performed. Success rates, complications, transjugular intrahepatic portosystemic shunt patency and clinical progression were examined. RESULTS Transjugular intrahepatic portosystemic shunt was attempted in 28 patients (13 cirrhotics). Indications were: presurgery/transplantation (2), worsening of ascites (2), variceal bleeding (15 - 8 elective), refractory ascites (3), portal biliopathy (3) and portal vein thrombosis complicating Budd-Chiari syndrome (2). Transjugular intrahepatic portosystemic shunt was placed successfully in 19 of 28 (73%); 23 of 28 had complete portal vein thrombosis and 9 of 23 had cavernous transformation and transjugular intrahepatic portosystemic shunt was successfully placed in six of these. In the 19 patients with transjugular intrahepatic portosystemic shunt, the mean follow-up was 18.1 months (range 5-70): six patients had stent revisions; three had liver transplantation, one died of bleeding. Most cirrhotic patients had an improvement in the Child-Pugh score. In the failed transjugular intrahepatic portosystemic shunt group, two of nine died, and three had further bleeding. CONCLUSIONS Transjugular intrahepatic portosystemic shunt should be considered for selected patients with symptomatic complete portal vein thrombosis with/without cavernous transformation, as clinical improvement and less rebleeding occur when transjugular intrahepatic portosystemic shunt placement is successful.
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Affiliation(s)
- M Senzolo
- Liver Transplantation and Hepatobiliary Unit, Royal Free & University College Medical School, London, UK
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37
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Gimeno FA, Calvo J, Loinaz C, Meneu JC, Pérez B, Gomez R, Jiménez C, Abradelo M, Moreno A, Sesma A, García I, Moreno E. Comparative analysis of the results of orthotopic liver transplantation in patients with and without portal vein thrombosis. Transplant Proc 2006; 37:3899-903. [PMID: 16386578 DOI: 10.1016/j.transproceed.2005.10.085] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Portal vein thrombosis (PVT), which had been considered an absolute contraindication to orthotopic liver transplantation (OLT), is currently considered a risk factor that increases morbi-mortality. The objective of this study was to compare OLT outcomes in patients with vs without PVT. MATERIALS AND METHODS Between April 1986 and December 2003, a sample of 83 patients with PVT was compared with another sample of 83 patients without PVT among 962 OLT performed in our department. RESULTS Both groups were homogeneous in terms of epidemiological variables, surgical technique, immunosuppression, and donor-related variables. There were no differences with respect to graft function during the first week following surgery. Surgical time and anhepatic phase duration was longer in the PVT group, albeit the differences were not significant. PVT patients also required more transfusions; a strong statistical association was observed with respect to blood (P = .12) and plasma (P = .11) transfusions and statistically significant differences regarding platelet transfusions (P = .02). Time on mechanical ventilation and the length of stay in the ICU were longer but not significant among PVT patients. The only statistically significant difference was the incidence of portal rethrombosis (P = .02). With respect to mean and global patient and graft actuarial survivals after 1, 3, 5, and 10 years, we have observed no significant intergroup differences, although both patient (P = .48; NS) and graft (P = .96, NS) survivals were lower among PVT cases. CONCLUSIONS PVT should not only cease to be considered a contraindication for OLT, but there were no significant differences between the outcomes despite this finding.
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Affiliation(s)
- F A Gimeno
- Servicio de Cirugía General, Aparato Digestivo y Trasplante de Organos Abdominales (Prof. E. Moreno González), Hospital Universitario 12 de Octubre, Madrid, Spain
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38
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Abstract
Portal hypertension is a complication of liver cirrhosis that may itself cause complications such as variceal bleeding, ascites and hepatorenal syndrome. There are several options for symptomatic treatment including drug therapy, endoscopy, transjugular intrahepatic portosystemic shunt (TIPS), and various surgical procedures, notably liver transplantation, the only causal treatment. The indication for liver transplantation has to be defined carefully. Progression of the primary disease, evaluation of comorbidity and overall prognosis have to be considered. Conservative symptomatic treatment is used for bridging purposes until liver transplantation can be provided to cure portal hypertension and the underlying primary disease. Careful timing of the transplantation is necessary as well as reorganization of the waiting lists by introducing new priority systems as the Model for End-Stage Liver Disease (MELD) in order to reduce mortality. Furthermore, living donor liver transplantation and split liver transplantation are methods to enlarge the donor pool, and thus accessibility of transplantation to a greater number of patients. This review evaluates the indication of liver transplantation in the treatment of portal hypertension.
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Affiliation(s)
- J Klupp
- Charité, Campus Virchow Clinic, Berlin, Germany.
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39
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Robles R, Fernandez JA, Hernández Q, Marín C, Ramírez P, Sánchez-Bueno F, Luján JA, Rodríguez JM, Acosta F, Parrilla P. Eversion thromboendovenectomy in organized portal vein thrombosis during liver transplantation. Clin Transplant 2004; 18:79-84. [PMID: 15108774 DOI: 10.1111/j.1399-0012.2004.00120.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Portal thrombosis is no longer considered a contraindication for transplantation because of the technical experience acquired in the field of liver transplantation and the development of various surgical techniques. All the same, the results obtained in portal thrombosis patients are at times suboptimal, and the surgical technique used (thromboendovenectomy or veno-venous bypass) is also controversial. Between May 1988 and December 2001, 455 liver transplants were performed, of which 32 (7%) presented portal vein thrombosis. Of these, eight belonged to the first 227 transplants (group I), and 24 to the other 228 (group II). Of the 32 cases with portal thrombosis, 20 (62%) were type Ib, seven (22%) type II/III and five (16%) type IV. Twenty-two were males (69%), with a mean age of 50 yr (range: 30-70 yr); the thrombosis in all cases developed over a cirrhotic liver: 15 cases of an ethanolic origin, 11 because of hepatitis C virus, two cases of autoimmune aetiology, one case of primary biliary cirrhosis, one case because of hepatitis B virus and two cases of a cryptogenic origin. Five cases had a history of surgical treatment for portal hypertension. The surgical method in all cases consisted of an eversion thromboendovenectomy (ETEV) under direct visual guidance, with occlusion of the portal flow using a Fogarty balloon. Once re-canalization was achieved, we performed local heparinization and end-to-end portal anastomosis. In no case was systemic post-operative heparinization performed. In the 32 cases in which thrombectomy was attempted it was achieved in 31 of them (96%), failing only in a case of type IV thrombosis, which was resolved by portal arterialization. Of the 31 successful cases, only one with type IV thrombosis re-thrombosed. The 5-yr survival rate of the patients in the series was 69%, with 10 patients dying, of whom only two from causes related to the thrombosis and the thrombosis treatment, both with type IV thrombosis. The ideal treatment for portal thrombosis during liver transplantation is controversial and depends on its extension and the experience of the surgeon. In our experience, ETEV resolves most thromboses (types I, II and III), but management of type IV, which occasionally can be treated with this technique, may require more complex procedures such as bypass, portal arterialization or cavoportal haemitransposition.
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Affiliation(s)
- Ricardo Robles
- Department of Surgery I, Hepatic Surgery and Liver Transplant Unit, Virgen de la Arrixaca University Hospital, El Palmar (Murcia), Spain
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40
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Sainz-Barriga M, Baccarani U, Risaliti A, Gasparini D, Sponza M, Adani GL, Toniutto PL, Avellini C, Ramacciato G, Bresadola F. Successful minimally invasive management of late portal vein thrombosis after splenectomy due to splenic artery steal syndrome following liver transplantation: a case report. Transplant Proc 2004; 36:558-9. [PMID: 15110593 DOI: 10.1016/j.transproceed.2004.02.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Portal vein thrombosis (PVT) after liver transplantation (OLT), which occurs in 1% to 2.7% of cases, can compromise patient and graft survival. Percutaneous transhepatic portal vein angioplasty offers an option to treat PVT, diminishing surgically related morbidity and the need for retransplantation. We describe a case of late PVT after OLT, which was successfully treated by a minimally invasive percutaneous transhepatic approach using both mechanical fragmentation and pharmacologic lysis of the thrombus followed by anticoagulation. The patient has had a good clinical course with normal graft function and patent portal blood flow at 6-month follow-up. This case report confirms the possibility of successful recanalization of the portal vein in a patient with late PVT after liver transplantation. Sustained anticoagulation/antiaggregation therapy for at least 6 months after the procedure is advisable.
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Affiliation(s)
- M Sainz-Barriga
- Department of Surgery and Transplantation Unit, University of Udine, Udine, Italy.
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41
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Abstract
BACKGROUND Throughout the history of liver transplantation many improvements have been made in the field of surgical technique. It is beyond the scope of this paper to review all aspects of surgical technique in liver transplantation; thus, in this review we focus on the description of our current technique in most cases, which is orthotopic liver transplantation with preservation of the inferior vena cava and temporary portocaval shunt. We advocate this technique because it has been demonstrated that it achieves better haemodynamic stability during the anhepatic phase, transfusion can be reduced and renal function is improved. The different options for vascular anastomoses are described, particularly the options for arterial anastomoses in case of finding a non-adequate recipient hepatic artery. Technical possibilities for patients with preoperative portal vein thrombosis and the procedure in case of domino or sequential liver transplantation are further explained.
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Affiliation(s)
- L Lladó
- Liver Transplant Unit, Department of Surgery, Hospital Bellvitge, University of BarcelonaSpain
| | - J Figueras
- Liver Transplant Unit, Department of Surgery, Hospital Bellvitge, University of BarcelonaSpain
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42
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Robles R, Fernández JA, Hernández Q, Marin C, Ramirez P, Sánchez Bueno F, Luján JA, Rodriguez JM, Acosta F, Parrilla P. Eversion thromboendovenectomy for organized portal vein thrombosis encountered during liver transplantation. Transplant Proc 2003; 35:1915-7. [PMID: 12962847 DOI: 10.1016/s0041-1345(03)00599-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Due to the technical experience acquired in the field of liver transplantation portal vein thrombosis is no longer considered a contraindication for transplantation. Nevertheless, the results obtained in patients with portal vein thrombosis are at times suboptimal, and there is no consensus on the appropriate surgical technique. PATIENTS AND METHODS Among the 455 liver transplants performed between May 1988 and December 2001, 32 (7%) presented with portal vein thrombosis. Twenty (62%) were type Ib, seven (22%) type II/III, and five (16%) type IV. Twenty-two were men (69%), with a mean age of 50 years (range: 30-70 years); the thrombosis in all cases developed in a cirrhotic liver. The surgical method in all cases consisted of an eversion thromboendovenectomy under direct visual guidance, with occlusion of the portal flow using a Fogarty balloon. RESULTS Among the 32 cases undergoing thrombectomy, 31 (96%) were successful with a failure in a case of type IV thrombosis, which was resolved by portal arterialization. Of the 31 successful cases, only one with type IV thrombosis rethrombosed. The 5-year survival rate of the patients in the series was 69%. Only two patients died from causes related to the thrombosis, both showing type IV thrombosis. CONCLUSION The ideal treatment for portal thrombosis during liver transplantation depends on its extension and on the experience of the surgeon. In our experience, eversion thromboendovenectomy resolves most thromboses (types I, II, and III), but management of type IV, which occasionally can be treated with this technique, may require more complex procedures such as bypass, portal arterialization or cavoportal hemitransposition.
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Affiliation(s)
- R Robles
- Department of Surgery I, Hepatic Surgery and Liver Transplant Unit, Virgen de la Arrixaca University Hospital, El Palmar, Spain
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43
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Bernardos A, Serrano J, Gomez MA, Garcia I, Tamayo MJ, Pareja F, Diaz C, Martin C. Portal vein thrombosis: an emergency solution for blood flow in liver transplantation. Transpl Int 2003. [DOI: 10.1111/j.1432-2277.2003.tb00356.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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44
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Settmacher U, Stange B, Schaser KD, Puhl G, Glanemann M, Steinmuller T, Heise M, Neuhaus P. Primary permanent arterialization of the portal vein in liver transplantation. Transpl Int 2003. [DOI: 10.1111/j.1432-2277.2003.tb00325.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Robles R, Ángel Fernández J, Hernández Q, Marín C, Ramírez P, Sánchez-Bueno F, Antonio Luján J, Manuel Rodríguez J, Acosta F, Parrilla P. Tromboendovenectomía de eversión en la trombosis organizada de la vena porta durante el trasplante hepático. Cir Esp 2003. [DOI: 10.1016/s0009-739x(03)72210-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Dumortier J, Czyglik O, Poncet G, Blanchet MC, Boucaud C, Henry L, Boillot O. Eversion thrombectomy for portal vein thrombosis during liver transplantation. Am J Transplant 2002; 2:934-8. [PMID: 12482145 DOI: 10.1034/j.1600-6143.2002.21009.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Portal vein thrombosis (PVT) has been seen as an obstacle to orthotopic liver transplantation (OLT), but recent data suggest that favorable results may be achieved in this group of patients. The aim of this study was to analyze the incidence, management, and survival of patients with PVT undergoing primary OLT with thrombectomy. Between October 1990 and August 2000, 468 liver transplantations were performed in our center and portal vein thrombosis was present in 38 patients (8.1%). Preoperative diagnosis, extension, intraoperative management, postoperative recurrence of portal vein thrombosis, and 1-year actuarial survival rates were retrospectively studied. Preoperative diagnosis was made in 17 cases (44.7%). In all patients, portal flow was restored after portal vein thrombectomy, followed by usual end-to-end portal anastomosis. All patients received preventive low-weight heparin from day 2 to hospital discharge, and then aspirin. Rethrombosis was observed in one patient with extended splanchnic thrombus. The 1-year actuarial patient survival rate was 83.7%, and did not significantly differ from the patients without portal vein thrombosis (86.7%). Our results suggest that portal vein thrombosis is often partial and thus difficult to diagnose preoperatively: it can be managed successfully during surgery by thrombectomy, except when there is complete splanchnic veins thrombosis; and it did not affect 1-year survival.
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Affiliation(s)
- Jérĵme Dumortier
- Unité de Transplantation Hépatique, Hôpital Edouard Herriot, 69437 Lyon Cedex 03, France
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Lacerda CM, de Melo PSV, Amorim A, Carvalho G, Pereira LB. The left gastric vein as an alternative to portal reconstruction in orthotopic liver transplantation. Transplant Proc 2002; 34:1216-7. [PMID: 12072319 DOI: 10.1016/s0041-1345(02)02743-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- C M Lacerda
- General Surgery Division, Oswaldo Cruz University Hospital (OCUH), University of Pernambuco (UPE), Recife, Brazil.
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Molmenti EP, Roodhouse TW, Molmenti H, Jaiswal K, Jung G, Marubashi S, Sanchez EQ, Gogel B, Levy MF, Goldstein RM, Fasola CG, Elliott EE, Bursac N, Mulligan D, Gonwa TA, Klintmalm GB. Thrombendvenectomy for organized portal vein thrombosis at the time of liver transplantation. Ann Surg 2002; 235:292-6. [PMID: 11807371 PMCID: PMC1422428 DOI: 10.1097/00000658-200202000-00019] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine the efficacy of portal thrombendvenectomy in cases of portal vein thrombosis at the time of orthotopic liver transplantation. SUMMARY BACKGROUND DATA Portal vein thrombosis (PVT) has been reported to have an incidence of 2% to 39% in end-stage liver disease. Multiple techniques have been suggested to treat this finding. Several reports have suggested suboptimal results after liver transplantation in recipients with PVT. METHODS The authors prospectively collected data on 1,546 patients who underwent an initial orthotopic liver transplant at the authors' institution between December 1984 and October 1999. There were 820 male patients and 726 female patients. All recipients received either cyclosporine or tacrolimus immunosuppression. Intraoperative flows of the portal vein and hepatic artery were routinely measured. Duplex sonography was routinely performed on the first postoperative day and routinely 1, 2, 5, and 10 years after transplantation. Eighty-five patients underwent thrombendvenectomy for organized thrombus partially or completely occluding the portal vein. Postoperative treatment included low-molecular-weight dextran for 48 hours and daily aspirin for 3 months. There were 53 male patients and 32 female patients. The PVT group was compared with a control group consisting of transplant recipients without PVT. RESULTS When compared with the control group, PVT patients were older at the time of transplantation and had a higher incidence of liver disease secondary to cryptogenic cirrhosis and Laennec's cirrhosis. There were no significant differences among both groups for 1-, 3-, and 6-year patient and graft survival rates. CONCLUSIONS Thrombendvenectomy provides a rapid resolution of an otherwise complex problem. It is the authors' procedure of choice in cases of organized PVT at the time of transplantation. Operative time and length of stay in the intensive care unit are not prolonged, and patient and graft survival rates are not compromised.
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Liatsos C, Vlachogiannakos J, Patch D, Tibballs J, Watkinson A, Davidson B, Rolles K, Burroughs AK. Successful recanalization of portal vein thrombosis before liver transplantation using transjugular intrahepatic portosystemic shunt. Liver Transpl 2001; 7:453-60. [PMID: 11349268 DOI: 10.1053/jlts.2001.23914] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A frequent complication in patients with end-stage liver disease is portal vein thrombosis (PVT). Although PVT is not considered an absolute contraindication to orthotopic liver transplantation (OLT), more complex surgery is required and patients have more postoperative complications and greater mortality rates. We describe 2 patients who experienced complete PVT either while waiting for liver transplantation or during the workup, resulting in acute deterioration of liver function. Recanalization of the portal vein was successfully performed in both patients using transjugular intrahepatic portosystemic stent shunt (TIPS), and patency was maintained by the addition of anticoagulation therapy. They subsequently underwent successful OLTs and remain well. In conclusion, we believe that TIPS placement can be performed safely in patients with recent PVT, ensuring the patency of the portal vein until OLT.
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Affiliation(s)
- C Liatsos
- Liver Transplantation and Hepatobiliary Medicine and the Department of Radiology, Royal Free Hospital, London, UK
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Muscari F, Suc B, Fourtanier G, Escat J. [Liver transplantation in the presence of a non-functional portal vein: an original technique]. ANNALES DE CHIRURGIE 2001; 126:111-7. [PMID: 11284100 DOI: 10.1016/s0003-3944(00)00473-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
STUDY AIM The aim of this retrospective study was to report an original technique for heterotopic liver transplantation with the graft in the left hypochondrium, and to discuss the indications and limitations of this technique. PATIENTS AND METHOD Over the past ten years, four patients were treated by this technique; this constitutes 2% of all liver transplantations carried out during this period. RESULTS No immediate per- or postoperative mortality related to the surgical procedure was noted. Moreover, no severe hemodynamic complications occurred during the per- or postoperative period. In three out of four cases, hepatic function was fully restored within 48 hours. Long-term survival (50 and 97 months) was observed in two patients. CONCLUSION Heterotopic liver transplantation in the left hypochondrium is an alternative to orthotopic liver transplantation; it is a technique that is easy, non-aggressive, and with good long-term results. It is indicated in cases where the main portal vein is non-functional (following total thrombosis or porto-caval shunt), and orthotopic liver transplantation is therefore not possible.
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Affiliation(s)
- F Muscari
- Service de chirurgie générale et digestive, hôpital de Rangueil, 31045 Toulouse, France.
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