Effect of liver transplantation on spleen size, collateral veins, and platelet counts. World J Surg. 2010;34:320-326. [PMID: 20012612 DOI: 10.1007/s00268-009-0314-x]

Preventing Small-for-size Syndrome in Living Donor Liver Transplantation: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference

Small-for-size syndrome (SFSS) is a well-recognized complication following liver transplantation (LT), with up to 20% developing this following living donor LT (LDLT). Preventing SFSS involves consideration of factors before the surgical procedure, including donor and recipient selection, and factors during the surgical procedure, including adequate outflow reconstruction, graft portal inflow modulation, and management of portosystemic shunts. International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplant Society of India Consensus Conference was convened in January 2023 to develop recommendations for the prediction and management of SFSS in LDLT. The format of the conference was based on the Grading of Recommendations, Assessment, Development, and Evaluation system. International experts in this field were allocated to 4 working groups (diagnosis, prevention, anesthesia, and critical care considerations, and management of established SFSS). The working groups prepared evidence-based recommendations to answer-specific questions considering the currently available literature. The working group members, independent panel, and conference attendees served as jury to edit and confirm the final recommendations presented at the end of the conference by each working group separately. This report presents the final statements and evidence-based recommendations provided by working group 2 that can be implemented to prevent SFSS in LDLT patients.

Emergency transileocolic vein obliteration for life-threatening bleeding from gastric varices

We report a case of life-threatening bleeding from gastric varices in a patient with alcoholic cirrhosis, which was treated by emergency transileocolic vein obliteration (TIO). A 46-year-old male with a massive hematemesis was transported to our hospital by ambulance. Contrast-enhanced computed tomography demonstrated large gastric varices. Temporary hemostasis using balloon tamponade was attempted, however, bleeding could not be controlled, and his vital signs were unstable despite massive blood transfusions. First, endoscopic treatment was attempted, but the visual field could not be secured due to massive bleeding. Therefore, emergency TIO under general anesthesia was attempted. After laparotomy, 5 Fr. sheath was inserted into the ileocolic vein. Posterior and left gastric veins, which were the blood supply routes of gastric varices, were identified and embolized using microcoils and a 50% glucose solution. Hemostasis was achieved and vital signs recovered. Three days after TIO, transjugular retrograde obliteration was attempted successfully to embolize the residual gastric varices. After the procedures, his condition improved. We conclude that emergency TIO is a useful rescue option for life-threatening bleeding from gastric varices if endoscopic treatment or balloon tamponade is ineffective.

Verification of thrombus formation just after endoscopic injection sclerotherapy with ligation for esophagogastric varices by venous phase of left gastric arteriography

Management of hepatic venous pressure gradient (HVPG) is important in the treatment of portal hypertension. We report a case that was treated by a hybrid procedure combining endoscopic injection sclerotherapy with ligation (EISL), left gastric artery embolization (LGE), and partial splenic artery embolization (PSE) based on a new concept ``splanchnic caput Medusae.'' The venous phase of left gastric arteriography just after EISL demonstrated thrombus formation in the gastric varices and the cardiac branch of the left gastric vein. The para-esophageal vein and lesser curvature branch of the left gastric vein were not affected. HVPG decreased from 14 to 11 mmHg immediately after LGE and PSE. 3D-CT reconstruction portal image revealed that the portal system reversed to almost normal form. This is the first case report in which thrombus formation in gastric varices and cardiac branch just after EISL could be demonstrated by the venous phase of left gastric arteriography.

Management of spontaneous portosystemic shunts at the time of liver transplantation: treatment or observation? Results of a systematic review

BACKGROUND

Optimal treatment of spontaneous portosystemic shunts (SPSS) during liver transplantation (LT) remains debated. We systematically reviewed the literature on definitions, treatment and outcomes of patients presenting SPSS undergoing LT.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used PubMed to retrieve all studies dealing with SPSS and LT between January 1987 and January 2020. The primary endpoints were definitions and outcomes according to the management of SPSS (treatment vs observation).

RESULTS

Thirteen studies detailing the management of 962 SPSS were retrieved. Hemodynamically significant SPSS were defined as those having diameter ≥ 10 mm in 41% (n = 395) of patients. SPSS were splenorenal (42%), cavo-gastric (15.2%), umbilical (7.4%), mesenterico-caval (n = 31; 3.2%), mesenterico-renal (0.1%) and unreported (31.9%), respectively. At the time of LT 372 shunts (38.7%) were treated while 590 were observed (61.3%). During a follow-up time ranging from 4 months to 5 years, the reported overall survival (OS) at 1 year was not significantly different except for one study. Portal vein anastomosis complications (i.e. reduced flow, stenosis or thrombosis) were similarly reported in observed [n = 26 (4%)] and ligated SPSS [n = 10 (2%)] (p = 0.22) but the rate of relaparotomy was significantly higher in observed SPPS (16 vs 2; p = 0.01) to rescue post LT portal vein thrombosis (n = 6) and reduced portal flow and graft dysfunction (n = 10).

CONCLUSIONS

There was a heterogeneous management of SPSS during LT in the literature. Ligation of SPPS did not reduce vascular complications neither improved survival. A randomized prospective study might contribute to identify best management of SPSS at time of LT.

An emergency hybrid procedure that combines endoscopic treatment with partial splenic embolization for bleeding esophagogastric varices

Management of splenomegaly is important in the treatment of portal hypertension. We report 2 cases who were treated by an emergency hybrid procedure combining endoscopic treatment and partial splenic embolization (PSE) based on a new concept "splanchnic caput Medusae". Case 1 with refractory esophageal variceal bleeding due to alcoholic liver cirrhosis was treated by endoscopic injection sclerotherapy (EIS) with ligation and PSE at the same time. Case 2 with gastric variceal bleeding due to polycystic liver disease was treated by EIS using n-butyl-2-cyanoacrylate and PSE at the same time. Six days after the hybrid procedure, transjugular retrograde obliteration was added. In both cases, post-treatment 3D-CT reconstruction images revealed that the spleen-portal system reversed to almost normal form. We conclude that an emergency hybrid procedure combining endoscopic treatment and PSE is effective for patients with bleeding esophagogastric varices.

Do Natural Portosystemic Shunts Need to Be Compulsorily Ligated in Living Donor Liver Transplantation?

BACKGROUND

Natural portosystemic shunt ligation practices in liver transplant vary widely across transplant centres and are frequently undertaken to prevent the serious consequence of portal steal phenomenon. No concrete indications have so far been convincingly identified for their management in living donor liver transplant.

METHODS

We retrospectively studied the outcome of 89 cirrhotic patients who either did (n = 63) or did not (n = 25) undergo shunt ligation during living donor liver transplantation between 2017 and 2020.

RESULTS

The incidence of early allograft dysfunction/nonfunction (P = 1.0) and portal venous complications (P = 0.555) were similar between the two groups. Although overall complications, biliary complications, and the composite of Grade III and IV complications were significantly higher in the nonligated group (P = 0.015, 0.052 and 0.035), 1- year graft and patient survival were comparable between them (P = 0.524).

CONCLUSION

We conclude that shunt ligation in living donor liver transplantation may not always be necessary if adequate portal flow, good vascular reconstruction, and good graft quality have been ensured.

Covered Transjugular Intrahepatic Portosystemic Shunt Improves Hypersplenism-Associated Cytopenia in Cirrhosis

BACKGROUND

Patients with cirrhosis often develop portal hypertension-associated splenomegaly and hypersplenism, potentially causing severe cytopenia.

AIMS

Systematic assessment on the impact of transjugular intrahepatic portosystemic shunt (TIPS) implantation on platelet count (PLT), hemoglobin (Hb), and white blood cell count (WBC).

METHODS

Patients with cirrhosis undergoing covered TIPS implantation were retrospectively included. Patients with malignancies or hematologic disorders were excluded. Hematology lab work was recorded at baseline (pre-TIPS) and at regular intervals after TIPS.

RESULTS

One hundred ninety-two patients (male: 72.4%, age: 56 ± 10 years; MELD: 12.1 ± 3.6) underwent TIPS implantation. Higher-grade (≥ G2) thrombocytopenia (PLT < 100 G/L) was present in 54 (28.7%),  ≥ G2 anemia (Hb < 10 g/dL) in 57 (29.7%), and  ≥ G2 leukopenia (WBC < 2 G/L) in 3 (1.6%) patients pre-TIPS, respectively. Resolution of ≥ G2 thrombocytopenia, anemia, and leukopenia occurred in 24/55 (43.6%), 23/57 (40.4%), and 2/3 (66.7%), respectively. Similar results were also observed in the subgroup of patients without 'bleeding' TIPS-indication, with improvements of G ≥ 2 thrombocytopenia and of G ≥ 2 anemia in 19.8% and 10.2% of patients after TIPS, respectively.

CONCLUSIONS

Thrombocytopenia, anemia, and leukopenia frequently improved after TIPS. Therefore, moderate- to higher-grade thrombocytopenia should not be regarded as a contraindication against TIPS, but rather be considered in case of severe thrombocytopenia-particularly prior to surgery or interventions.

Sarcoidosis-lymphoma syndrome with portal hypertension: diagnostic clues and approach

Sarcoidosis-lymphoma syndrome associated with portal hypertension is very rare. A 68-year-old female presented with a 5 kg weight loss in 6 months. Soluble interleukin-2 receptor activity was increased and total platelet count was decreased. Contrast-enhanced computed tomography showed the presence of hepatosplenomegaly and a 3 cm-sized tumor in segment 3 of the liver. The hepatic venous catheterization showed mild portal hypertension. On fluorodeoxyglucose-positron emission tomography/computed tomography, progressive malignant lymphoma was suspected. However, bone marrow biopsy showed multiple noncaseating granulomas. A laparoscopic liver biopsy revealed that the liver tumor had features of Hodgkin lymphoma. There were multiple noncaseating epithelioid granulomas in the portal tracts of the liver. Splenectomy for splenomegaly and partial hepatectomy for the liver tumor were performed. Pathological examination of the resected specimens revealed multiple noncaseating epithelioid granulomas in the liver and spleen. Histopathology of the liver tumor confirmed classic Hodgkin lymphoma with mixed cellularity. We conclude that hepatic venous catheterization, positron emission tomography/computed tomography, and pathological examinations of bone marrow, liver, and spleen are crucial for the diagnosis of sarcoidosis-lymphoma syndrome associated with portal hypertension.

Stepwise partial splenic embolization for portal hypertension based on a new concept: Splanchnic caput Medusae

Management of splenomegaly with thrombocytopenia is important in the treatment of portal hypertension. We propose a new concept: “Splanchnic Caput Medusae” in which enlarged spleen is her face and portal collateral pathways are her snake hairs. We report 2 demonstrable cases who were treated based on this new concept. Case 1 with refractory esophageal varices and splenomegaly was treated by stepwise partial splenic embolization (PSE) and endoscopic injection sclerotherapy with ligation. Spleen/liver volume ratio changed from 0.33 to 0.10. Hepatic venous pressure gradient changed from 19 to 14 mmHg. Case 2 with mesenteric shunt and splenomegaly was treated by stepwise PSE and retrograde obliteration. Spleen/liver volume ratio changed from 0.70 to 0.05. Hepatic venous pressure gradient changed from 11 to 7 mmHg. In these 2 cases, 3D-CT reconstruction images after treatment revealed that spleen- portal system reversed almost to normal form. We conclude that splenomegaly and portal collateral pathways could be considered as “Splanchnic Caput Medusae” and have to be treated by stepwise PSE.

[Volume Measurements of Post-transplanted Liver of Pediatric Recipients Using Workstations and Deep Learning]

PURPOSE

The purpose of this study was to propose a method for segmentation and volume measurement of graft liver and spleen of pediatric transplant recipients on digital imaging and communications in medicine (DICOM) -format images using U-Net and three-dimensional (3-D) workstations (3DWS) .

METHOD

For segmentation accuracy assessments, Dice coefficients were calculated for the graft liver and spleen. After verifying that the created DICOM-format images could be imported using the existing 3DWS, accuracy rates between the ground truth and segmentation images were calculated via mask processing.

RESULT

As per the verification results, Dice coefficients for the test data were as follows: graft liver, 0.758 and spleen, 0.577. All created DICOM-format images were importable using the 3DWS, with accuracy rates of 87.10±4.70% and 80.27±11.29% for the graft liver and spleen, respectively.

CONCLUSION

The U-Net could be used for graft liver and spleen segmentations, and volume measurement using 3DWS was simplified by this method.

Pretransplantation splenomegaly frequently persists after liver transplantation and can manifest as hypersplenism and graft fibrosis - a retrospective study

The risk factors and clinical impact of post-transplantation splenomegaly (SM) are poorly understood. We investigated the predictors and impacts of post-transplantation SM in 415 LT patients at Kyoto University Hospital from April 2006 to December 2015. First, the predictors and clinical consequences of SM three years post-transplantation were analyzed among spleen-preserved recipients. Second, the clinical data of surviving recipients three years post-transplantation were compared between splenectomized and spleen-preserved recipients. There was no difference in indication for liver transplantation between these two groups. Third, survival outcomes were compared between splenectomized and spleen-preserved recipients. SM was determined as a SV/body surface area (BSA) higher than 152 ml/m² . In the first analysis, preoperative SM occurred in 79.9% recipients and SM persisted three years post-transplantation in 72.6% recipients among them. Preoperative SV/BSA was the only independent predictor of three year post-transplantation SM, which was associated with lower platelet (PLT), white blood cell (WBC) counts and significant graft fibrosis (21.4% vs. 2.8%). In the second analysis, spleen-preservation was related to lower PLT, WBC counts and a higher proportion of significant graft fibrosis (26.7% vs. 7.1%) three years post-transplantation. In the third analysis, spleen-preserved recipients showed worse survival than splenectomized recipients. In conclusion, preoperative SM frequently persists more than three years post-transplantation and is associated with subclinical hypersplenism, graft fibrosis, graft loss, and even death.

Flood syndrome managed by partial splenic embolization and percutaneous peritoneal drainage

Flood syndrome is a rare complication of cirrhosis of liver accompanied by ascites and a sudden rupture of umbilical hernia causing drainage of ascitic fluid from abdominal cavity. We report management of a case of Flood syndrome which was caused by rupture of incisional hernia. The clinical picture was similar to well described and widely accepted Flood syndrome. A 70-year-old female with decompensated hepatitis C cirrhosis was transported to the emergency department with a sudden drainage of ascitic fluid after sudden dehiscence of pre-existing incisional hernia and diffuse abdominal tenderness. Initially, she was managed by applying ostomy bag and diuretics to reduce the ascites. On 8th day of admission, a 16 Fr. drain was percutaneously placed in the left lower abdominal quadrant to divert the fluid from the abdominal wall defect. On 13th day, 80% partial splenic embolization (PSE) was attempted to control portal hypertension to reduce the ascites volume. After PSE, the hepatic venous pressure gradient reduced from 28 to 21cm H₂O. The peritoneal drain was removed on 16th day and she was discharged on 22nd day. We conclude that PSE and temporary percutaneous peritoneal drainage are useful option to manage Flood syndrome.

Comprehensive Analysis of Long-term Splenic Volume Changes in Pediatric Liver Transplant Patients: Does It Correlate With Adverse Graft Outcomes?

OBJECTIVES

Splenomegaly and hypersplenism caused by liver failure increase the mortality and morbidity of patients even after liver transplantation if they do not regress. We evaluated the relation of splenic volume change and transplanted liver function.

MATERIAL AND METHODS

A total of 59 of 207 pediatric patients who had liver transplantation between 2013 and 2018 in our institute were evaluated. The relation of spleen volume changes (splenic volume to standard splenic volume ratio [SV/SSV]) were measured at 0, 1, 6, 12, 24, and 36 months of follow-up by constructing electronic three-dimensional structure of the spleen at dynamic computed tomography (CT), and the course of liver functions were evaluated.

RESULTS

The SV/SSV ratio decreases in the first postoperative 6 months. After 6 months, SV increases and SV/SSV increases gradually. In a normal functioning graft, SV/SSV significantly decreased in all time points (P < .001). In patients with adverse events, SV/SSV started to increase after 6 months. In patients with fulminant hepatic failure, SV/SSV started to increase after postoperative 6 months. Adverse events in patients with fulminant hepatic failure were more than the patients with chronic liver disease (58% vs 28%). There was an inverse correlation between SV/SSV and thrombocyte levels (P < .001).

CONCLUSIONS

SV/SSV seems to be correlated to the adverse events (ie, rejection). Together with thrombocyte levels, it can be used as a noninvasive test for follow-up of transplant patients in terms of adverse events in graft function.

Bacterial meningitis after incomplete retrograde obliteration for duodenal varices with encephalopathy: A case report

We report a case of bacterial meningitis in a 72-year-old female with nonalcoholic steatohepatitis who underwent incomplete retrograde obliteration for duodenal varices with encephalopathy. Two months after incomplete retrograde obliteration, she became febrile, drowsy, and was transported to hospital. Her serum ammonia level was normal. Endoscopy revealed that previously embolized coil was partially migrated into the duodenal lumen. Cerebrospinal fluid examination confirmed the diagnosis of bacterial meningitis. She was treated with intravenous antibiotics. As there was a risk of bleeding, trans-ileocolic vein obliteration of duodenal varices was attempted. The patient slowly recovered and was discharged. This case indicated two problems could occur by coil migration after incomplete retrograde obliteration for duodenal varices with encephalopathy. One was bacterial meningitis and the other was risk of bleeding from duodenal varices. We conclude that cerebrospinal fluid examination is recommended for patients with high fever and abnormal mental status after incomplete retrograde obliteration, and immediate complete obliteration should be attempted for a risk of bleeding.

A Single-Center Experience in Portal Flow Augmentation in Liver Transplantation With Prior Large Spontaneous Splenorenal Shunt

Large portosystemic shunts may cause portal steal syndrome in liver transplantation (LT). Because of the possible devastating consequences of the syndrome, the authors recommend perioperative management of these large shunts. Fourteen adult recipients who underwent portal flow augmentation, including left renal vein ligation (LRVL), renoportal anastomosis (RPA), shunt ligation (SL), and splenic vein ligation (SVL) for large spontaneous splenorenal shunt (SSRS), are included in this study, and the results were analyzed. A total of 13 patients had a large SSRS, and in 1 patient, the large shunt was placed between the superior mesenteric vein and the right renal vein. LDLT was performed in 13 patients. LRVL (n = 5), SVL (n = 6), RPA (n = 2), SL (n = 1) were performed to the patients as graft inflow augmentation. The graft-recipient weight ratios (GRWR) were less than 0.8% in 5 patients (35.7%): 2 had LRVL, and 3 had SVL. Small-for-size syndrome (SFSS) occurred only in these 2 patients with LRVL (GRWR ≤0.8%) and, splenic artery ligation was performed for graft inflow modulation. No mortality or serious complications were reported during follow-up. We consider that in patients with large SSRS and small-for-size grafts, SVL can be performed safely and with satisfactory outcomes.

Intervention on Spontaneous Splenorenal Shunt May Decrease the Incidence of Acute Kidney Injury After Liver Transplant

OBJECTIVES

Spontaneous splenorenal shuntis a type of portosystemic shunt that develops frequently in the setting of chronic portal hypertension. It remains controversial whether shuntinterventions during liver transplant improve transplant outcomes.

MATERIALS AND METHODS

We conducted a retrospective comparison between deceased-donor liver transplant recipients who received spontaneous splenorenal shunt intervention and those who did not at a tertiary center between 2012 and 2017. Primary outcomes of interest included intraoperative transfusion requirement, hospital length of stay, acute kidney injury posttransplant, portal vein thrombosis, thrombocytopenia, and 1-year graft and patient survival.

RESULTS

Of 268 liver transplant recipients, 50 (18.6%) had large spontaneous splenorenal shunts pretransplant, with 45 patients having available radiologic and outcome data. Nine of 45 patients (20%) received shunt intervention, including pretransplant balloonoccluded retrograde transvenous obliteration (n = 5), intraoperative ligation of the left renal vein (n = 3), and intraoperative direct shunt ligation (n = 1). Demographic data, clinical characteristics, and Model for End-Stage Liver Disease scores were not different between the intervention and the nonintervention groups. Intraoperative transfusion, length of hospitalization, portal vein thrombosis, thrombocytopenia, and 1-year graft and patient survival were also similar between the 2 groups. However, the rate of posttransplant acute kidney injury was significantly lower in patients in the intervention group (0 cases vs 12 cases; odds ratio = 0.73; 95% confidence interval, 0.59-0.90). Patients with no SRS intervention (n = 36) were followed radiologically for 1 year posttransplant, with follow-up data showing complete resolution of spontaneous splenorenal shunt in just 4 patients (15%) and no changes in the remaining patients.

CONCLUSIONS

Peritransplant interventions for spontaneous splenorenal shunt may reduce posttransplant acute kidney injury. In patients without intervention, spontaneous splenorenal shunt predominantly persisted 1 year posttransplant.

Advances in research of spontaneous splenorenal shunt in patients with liver cirrhosis

Liver cirrhosis is the end stage of various chronic liver diseases. Spontaneous splenorenal shunt (SSRS) refers to abnormal blood vessels from the splenic vein to the renal vein, which are rich and thickened. SSRS formation may be due to the dilatation of pre-existing venules or neovascularization. SSRS can effectively reduce portal vein pressure, but it can also lead to a decrease of hepatic perfusion, which may be one of the reasons for insufficient hepatic perfusion after liver transplantation. In addition, toxic substances in the blood cannot be fully metabolized by the liver and directly enter the systemic circulation, leading to the development of hepatic encephalopathy. The treatment methods for SSRS include intervention and operation.

Factors Affecting Persistent Splenomegaly After Adult-to-Adult Living Donor Liver Transplantation Using a Left Lobe

BACKGROUND

The aim of the present study was to evaluate spleen volume (SV) and the factors influencing it after adult-to-adult living donor liver transplantation (A2LDLT) using a left lobe.

METHODS

Pretransplant computed tomography (CT) and post-transplant CT 2 years after A2LDLT were examined by volumetric analysis in 24 patients. We divided the recipients into the following 2 groups according to the post-transplant SV: >500 mL (Group A) and ≤500 mL (Group B). The factors affecting the change in post-transplant SV were compared between the 2 groups.

RESULTS

The mean pretransplant SV decreased significantly after A2LDLT. Platelet counts after living donor liver transplantation increased significantly relative to the pretransplant values. Post-transplant SV was >500 mL in 9 patients (Group A) and ≤500 mL in 15 (Group B). Pretransplant SV, platelet count, anhepatic time, operative time, intraoperative blood loss, post-transplant portal vein pressure >20 mm Hg, and post-transplant portal vein flow >250 mL/min/100 g graft weight showed significant differences between the 2 groups. Actual graft volume (GV) and GV/standard liver volume ratio showed no intergroup differences. Multivariate analysis showed that the only significant factor related to a post-transplant SV of >500 mL was the pretransplant SV. Post-transplant platelet counts were significantly increased from the pretransplant values in both Group A and Group B.

CONCLUSIONS

Pretransplant SV is the only significant factor predicting a SV of >500 mL after A2LDLT. However, even in patients with a SV of >500 mL, the platelet count increased significantly from the pretransplant value.

Long-term outcomes after stent insertion in patients with early and late hepatic vein outflow obstruction after living donor liver transplantation

Purpose

The purpose of this study was to describe the long-term effects of stenting in patients with hepatic venous outflow obstruction (HVOO), who underwent living donor liver transplantation (LDLT).

Methods

Between January 2000 and December 2009, 622 adult patients underwent LDLT at our hospital, and of these patients, 21 (3.3%) were diagnosed with HVOO; among these patients, 17 underwent stenting. The patients were divided into early or late groups according to the time of their HVOO diagnoses (cutoff: 60 days after liver transplantation).

Results

The median follow-up period was 54.2 months (range, 0.5–192.4 months). Stent insertion was successful in 8 of 10 patients in the early group and 6 of 7 in the late group. The 5-year primary patency rates were 46% and 20%, respectively. In both groups, patients with recurrent HVOO at the beginning showed kinking confirmed by venography. Patients who carried their stents for more than 3 years maintained long-term patency. There was no significant difference in spleen size between groups; however, when the groups were compared according to whether they maintained patency, spleens tended to be smaller in the patency-maintained group.

Conclusion

Unlike stenosis, if kinking is confirmed on venography, stenting is not feasible in the long term for patients with LDLT.

Ligation versus no ligation of spontaneous portosystemic shunts during liver transplantation: Audit of a prospective series of 66 consecutive patients

The management of large spontaneous portosystemic shunt (SPSS) during liver transplantation (LT) is a matter of debate. The aim of this study is to compare the short-term and longterm outcomes of SPSS ligation versus nonligation during LT, when both options are available. From 2011 to 2017, 66 patients with SPSS underwent LT: 56 without and 10 with portal vein thrombosis (PVT), all of whom underwent successful thrombectomy and could have portoportal reconstruction. The SPSS were either splenorenal (n = 40; 60.6%), left gastric (n = 16; 24.2%), or mesenterico-iliac (n = 10; 15.1%). Following portoportal anastomosis, the SPSS was ligated in 36 (54.4%) patients and left in place in 30 (45.5%) patients, based on the effect of the SPSS clamping/unclamping test on portal vein flow during the anhepatic phase. Intraoperatively, satisfactory portal flow was obtained in both groups. Primary nonfunction (PNF) and primary dysfunction (PDF) rates did not differ significantly between the 2 groups. Nonligation of SPSS was significantly associated with a higher rate of postoperative encephalopathy (P < 0.001) and major postoperative morbidity (P = 0.02). PVT occurred in 0 and 3 patients in the ligated and nonligated shunt group, respectively (P = 0.08). A composite end point, which included the relevant complications in the setting of SPSS in LT (ie, PNF and PDF, PVT, and encephalopathy) was present in 16 (44.4%) and 22 (73.3%) patients of the ligated and nonligated shunt group, respectively (P = 0.02). Patient (P = 0.05) and graft (P = 0.02) survival rates were better in the ligated shunt group. In conclusion, the present study supports routine ligation of large SPSS during LT whenever feasible. Liver Transplantation 24 505-515 2018 AASLD.

Tips and pitfalls in direct ligation of large spontaneous splenorenal shunt during liver transplantation

Patients with large spontaneous splenorenal shunts (SRSs) prove challenging during liver transplantation (LT), regardless of organizing portal vein (PV) thrombosis. Here, we detail the clinical outcomes of 26 patients who underwent direct ligation of large SRSs during LT. Direct ligation of large SRS was applied in poor portal flow during LT. We performed temporary test clamping of the SRS before direct ligation and applied PV pressure monitoring in patients who showed signs of portal hypertension, such as bowel edema. We retrospectively reviewed and evaluated their clinical outcomes. Among 843 patients who underwent LT between 2010 and 2015, 26 (3.1%) underwent direct ligation of SRS without any intraoperative event. Mean preoperative Model for End-Stage Liver Disease score was 16.7 ± 9.0. The main PV diameter on preoperative computed tomography was 8.3 ± 3.4 mm (range, 3.0-14.0 mm). SRS was easily identified at just below the distal pancreas and beside the inferior mesenteric vein in all patients. Accompanying PV thrombectomy was done in 42.3% of patients. Among 26 patients, massive and prolonged ascites was evident in 15.4% (n = 4) postoperatively. They were all living donor LT recipients with a small PV diameter (4.0-6.7 mm). Except for 1 patient who underwent splenic artery embolization, ascites was tolerable and well controlled by conservative management. There was a 7.7% rate of major complications related to direct ligation, including reoperation due to combined ligation of SRS along with a left renal vein at the confluence. Except for 1 hospital mortality due to sepsis, 25 patients (96.2%) are alive with no evidence of further PV complications. In conclusion, direct ligation of large SRS during LT is a safe and feasible method to overcome the effects of a large SRS. Liver Transplantation 23 899-906 2017 AASLD.

Individualized Immunosuppressive Protocol of Liver Transplant Recipient Should be Made Based on Splenic Function Status

BACKGROUND

Lymphocyte subsets play important roles in rejection in liver transplant recipients, and the effect of splenic function on these roles remains unknown. The aim of this study was to explore the feasibility to adjust immunosuppressive agents based on splenic function status through detecting the lymphocyte subsets in liver transplantBeijing recipients.

METHODS

The lymphocyte subsets of 49 liver transplant recipients were assessed in the 309th Hospital of Chinese People's Liberation Army between June 2014 and August 2015. The patients were divided into splenectomy group (n = 9), normal splenic function group (n = 24), and hypersplenism group (n = 16). The percentages and counts of CD4+ T, CD8+ T, natural killer (NK) cell, B-cell, regulatory B-cell (Breg), and regulatory T-cell (Treg) were detected by flow cytometer. In addition, the immunosuppressive agents, histories of rejection and infection, and postoperative time of the patients were compared among the three groups.

RESULTS

There was no significant difference of clinical characteristics among the three groups. The percentage of CD19+CD24+CD38+ Breg was significantly higher in hypersplenism group than normal splenic function group and splenectomy group (3.29 ± 0.97% vs. 2.12 ± 1.08% and 1.90 ± 0.99%, P = 0.001). The same result was found in CD4+CD25+FoxP3+ Treg percentage (0.97 ± 0.39% vs. 0.54 ± 0.31% and 0.56 ± 0.28%, P = 0.001). The counts of CD8+ T-cell, CD4+ T-cell, and NK cell were significantly lower in hypersplenism group than normal splenic function group (254.25 ± 149.08 vs. 476.96 ± 225.52, P= 0.002; 301.69 ± 154.39 vs. 532.50 ± 194.42, P= 0.000; and 88.56 ± 63.15 vs. 188.33 ± 134.51, P = 0.048). Moreover, the counts of CD4+ T-cell and NK cell were significantly lower in hypersplenism group than splenectomy group (301.69 ± 154.39 vs. 491.89 ± 132.31, P= 0.033; and 88.56 ± 63.15 vs. 226.00 ± 168.85, P = 0.032).

CONCLUSION

Splenic function status might affect the immunity of liver transplant recipients, that should be considered when we make immunosuppressive protocols.

Relationship Between Graft Liver Function and the Change of Graft Liver and Spleen Volumes After Technical Variant Liver Transplantation

BACKGROUND

Although there have been a few reports describing the changes of graft liver and spleen volumes after liver transplantation (LT), little is known about the relationship between graft liver function and the changes of these volumes after technical variant liver transplantation (TVLT). We therefore performed a retrospective study to investigate the relationship between graft liver function and these volumes after TVLT.

METHODS

We retrospectively investigated the cases of 140 TVLT procedures that were performed in our department between July 1987 and October 2012 and in which follow-up was conducted at our department. We calculated the graft liver volume to standard liver volume (GV/SLV) ratio, the spleen volume to standard spleen volume (SV/SSV) ratio, and the spleen volume to graft liver volume (S/L) ratio by CT volumetry. We clarified the relationship between graft liver function (according to the pathological findings) and the graft liver and spleen volumes at 2, 5, and 10 years after TVLT.

RESULTS

In the normal liver function group, the GV/SLV, SV/SSV, and S/L ratios decreased until 6 months after TVLT and then converged at 10 years after TVLT to 0.95, 1.27, and 0.27, respectively. In the graft liver failure group, the GV/SLV, SV/SSV, and S/L ratios at 10 years after TVLT were 0.67, 5.01, and 1.55, respectively. A significant correlation was observed between the GV/SLV ratio and the presence of mild liver fibrosis at 2 and 5 years after TVLT (P = .03 and P = .04, respectively).

CONCLUSIONS

Post-transplant CT-volumetry is a noninvasive and effective means of evaluating graft liver status.

Giant Splenorenal Shunt in a Young Patient with Autoimmune Hepatitis/Primary Biliary Cholangitis Overlap Syndrome and Portal Vein Thrombosis

We present a case of giant Splenorenal Shunt (SRS) associated with portal vein thrombosis in a 37-year-old woman with a twelve-year history of autoimmune hepatitis/primary biliary cholangitis overlap syndrome. At the moment of the CT examination laboratory tests showed creatinine 1.5 mg/dl, bilirubin 1.5 mg/dl, INR 3, and Na 145 mmol/l and the Model End-Stage Liver Disease score was 24. Extensive calcified thrombosis causing complete occlusion of the portal vein lumen and partially occluding the origin of the superior mesenteric vein was present and a small calcified thrombus in the Splenic Vein lumen was also evident. SRS was located among the spleen hilum and the left kidney with a maximum diameter of 3.25 cm and was associated with dilatation of left renal vein and inferior vena cava. After a multidisciplinary evaluation the patient was put on the Regional Liver Transplant waiting list and liver transplantation was performed successfully. Although portal vein thrombosis and SRS are common occurrences in cirrhotic patients, the impact in the natural history of the disease is still unclear. Careful management and accurate imaging protocols are essential in the evaluation of those patients.

Liver transplantation in a patient with complete portal vein thrombosis, is there a surgical way out? A case report

Introduction

Due to the complexity of the surgical procedure portal vein thrombosis (PVT) has long been considered an absolute contraindication to liver transplantation (LT). The presence of a large splenorenal shunt (SRS) could make portal anastomosis a valid option.

Presentation of case

We report the case of a 37-year-old female patient with Grade III PVT and a large SRS, who underwent orthotopic LT. Liver was implanted using a 1992-Belghiti piggyback technique and portal anastomosis was performed using the large spleno-renal shunt. We observed good graft reperfusion and postoperative Doppler ultrasound showed normal portal vein flow. She was discharged on postoperative day 7, with an excellent graft function. At six months follow-up, patient is alive with normal hepatic vascularization.

Discussion

Due to paucity of reports, there is currently no consensus on the indication to LT and/or surgical technique. In the present case, once the transplant benefit was evaluated, the Grade III PVT was not considered a contraindication to LT.

Conclusion

The presence of a Grade III PVT associated with a large SRS should not be considered a contraindication for LT, and the use of the shunt vein should be considered a feasible option to perform portal anastomosis.

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The Yerdel III–IV portal vein trombosis should not be considered an absolute controindication to liver transplantation

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The identification of a well represented spleno-renal shunt on the pre-operative imaging is essential to plan a liver transplantation

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Since the high risk surgery a transplant benefit must be evaluated in order to estimate the gain in terms of survival

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The operation must be lead by a high experienced liver transplant surgeon

Piceatannol increases the expression of hepatocyte growth factor and IL-10 thereby protecting hepatocytes in thioacetamide-induced liver fibrosis

Piceatannol is a polyphenolic analog of resveratrol that selectively inhibits the non-receptor tyrosine kinase-Syk. This study investigates the potential ability of piceatannol to attenuate liver fibrosis and protect hepatocytes from injury. Thioacetamide was injected in adult male mice (100 mg/kg, i.p., 3 times/week) for 8 weeks. Piceatannol (1 or 5 mg/kg per day) was administered by oral gavage during the last 4 weeks. Liver function biomarkers, tissue malondialdehyde (MDA), cytokeratin-18 (CK18), hepatocyte growth factor (HGF), and interleukin-10 (IL-10) were measured. Necroinflammation, fibrosis, expression of transforming growth factor (TGF)-β1, and α-smooth muscle actin (SMA) were scored by histopathological examination and immunohistochemistry. Obtained results showed ability of piceatannol (1 mg/kg) to restore liver function and reduce inflammation. It significantly (p < 0.001) reduced MDA, CK18, TGF-β1, and α-SMA expression, and increased HGF and IL-10. It can be concluded that piceatannol at low dose can inhibit TGF-β1 induced hepatocytes apoptosis and exerts an anti-inflammatory effect attenuating fibrosis progression.

Spontaneous Splenorenal Shunt in Liver Transplantation: Results of Left Renal Vein Ligation Versus Renoportal Anastomosis

BACKGROUND

Management of portal inflow to the graft in patients with spontaneous splenorenal shunts (SRS) is a matter of concern especially in case of large varices (more than 1 cm). In case of portal vein (PV) thrombosis (PVT), renoportal anastomosis (RPA) directly diverts the splanchnic and renal venous blood assuring a good portal inflow to the graft. Disconnection of the portacaval shunt by left renal vein ligation (LRVL) is another option but requires a patent PV. The indication of primary RPA rather than LRVL in patients with small native PV, especially in case of large graft, should be questioned in these complex cases of liver transplantation.

METHODS

From 1998 to 2012, 17 patients with RPA and 15 patients with LRVL were transplanted in our center. We compared these 2 techniques for short- and long-term results.

RESULTS

The rate of preliver transplantation PVT (76% vs 27%) and graft weight (1538 ± 383 g vs 1293 ± 216 g) was significantly higher in the RPA group. Renoportal anastomosis was performed in 4 cases of small but patent PV. Three-month mortality, morbidity, and massive ascitis were similar. No patient was retransplanted. One year after transplantation, PV diameter was still larger in RPA group. Three-year survival was similar (RPA: 79% vs LRVL: 53%, P = 0.1).

CONCLUSIONS

In cirrhotic patients transplanted with large splenorenal shunts, RPA and LRVL reach similar survivals. In case of complete PVT and failure of thrombectomy, the RPA offers satisfactory long-term results.

Thrombocytopenia, splenomegaly, and portal blood flow in patients who have undergone liver transplantation for cirrhosis

The platelet count (PC), the spleen size (SS), and the portal blood flow (PBF) have been independently studied in the perioperative period after orthotopic liver transplantation (OLT) for cirrhosis, but these parameters have not been described and analyzed in combination. We analyzed PC data and Doppler sonography measurements of SS and PBF from 125 adult patients before OLT and 1, 3, 6, 9, and 12 months after transplantation. A linear mixed model with fixed subject random intercepts was used. PCs increased significantly from 101.5 ± 68.5 × 10(9) /L before OLT to 162.4 ± 86 × 10(9) /L 1 month after OLT and remained stable for 1 year after the operation. PBF increased significantly from 619 ± 239 mL/minute before OLT to 1379 ± 491 mL/minute after OLT and remained stable during the first year. SS slowly decreased after OLT, but the decrease became significant only 9 months after the operation (13.8 ± 4.2 cm before OLT versus 11.7 ± 3.7 cm at 9 months, P < 0.05). The cirrhosis etiology did not influence the evolution of the parameters. With or without replication or interferon treatment before OLT, the hepatitis C group viruses did not influence PCs postoperatively. The evolution of SS was correlated to the evolution of PCs in the year after transplantation. In conclusion, PCs and PBF increase rapidly after OLT, whereas SS slowly decreases. The cirrhosis etiology does not influence the evolution of PCs. Thrombocytopenia and splenomegaly are 2 results of portal hypertension, but the rapid normalization of PBF does not completely or rapidly reverse these 2 phenomena.

Diagnosis of hypersplenism with the epinephrine stimulation test

PRINCIPLES: Hypersplenism can be defined by thrombocytopenia and/or neutropenia resulting from blood cell sequestration in an enlarged spleen. In multimorbid patients the differential diagnosis of cytopenia is challenging and currently there is no established test for diagnosing hypersplenism. METHODS: The epinephrine stimulation test (EST) measures changes in platelets, neutrophil counts and spleen size following a subcutaneous epinephrine injection. We retrospectively analysed the results of EST in 228 patients. RESULTS: Increases in neutrophils and platelets after epinephrine injection were significantly greater in patients with enlarged than in patients with normal size spleens. Using cutoffs of low, intermediate and high confidence EST was positive in 69.8% vs. 41.3% (low confidence), 49.6% vs. 17.4% (intermediate confidence) and 38.8% vs. 10.9% (high confidence) in patients with enlarged vs. normal size spleens. Changes in platelet and neutrophil counts correlated with each other and with changes in spleen size, confirming cell release from the spleen during EST. When stratified according to the underlying diagnosis, patients with liver disease had the strongest response to EST, patients with malignant haematological diseases the weakest. In addition the response to EST was significantly related to changes in platelet and neutrophil counts after splenectomy, confirming the validity of our test. No serious side effects occurred during EST. CONCLUSION: When used in a large patient cohort, EST is a safe and simple diagnostic test. In this exploratory study EST is of value in evaluating patients with cytopenia and a positive EST argues strongly for hypersplenism. Future studies should prospectively evaluate EST for the management of patients with splenomegaly.

Spleen: A new role for an old player?

The spleen could be considered a neglected organ. To date, it has been deemed an ancillary organ in portal hypertension or an organ localization in lymphoproliferative diseases, even though it has had significant attention in infectious diseases for some time. Now, it is thought to be central in regulating the immune system, a metabolic asset and involved in endocrine function with regard to nonalcoholic fatty liver disease. The main mechanisms involved in this complex network will be critically discussed in this article.

Change in platelet count in patients with hypersplenism subjected to liver transplantation

CONTEXT: Most patients subjected to liver transplantation presents hypersplenism, which is reversed after the operation. However, some patients remain with moderate to intense hypersplenism. OBJECTIVES: To study the effect of liver transplantation on platelet count in patients with hypersplenism. METHOD: Of a total of 233 patients who underwent liver transplantation, 162 were excluded from the present study because of occurrence of steroid-resistant rejection, absence of hypersplenism before the transplantation, absence of follow-up for at least 2 years or incomplete exams data. The electronic study protocols of the remaining 71 patients were reviewed to determine the demographics, etiology of cirrhosis, and results of pathologic examination of the explanted liver. Serial platelet count was obtained from the study protocol on the day before liver transplantation and 1, 2, 4, and 6 months and 1 year after liver transplantation. Statistical analysis was performed using the Student's t-test, chi-square test, and Spearman's correlation test. RESULTS: Posttransplant platelet count at all time intervals was significantly higher than the pretransplant value (P<0.001 for all time intervals). Thrombocytopenia was reversed (platelet count >100,000/mm³) in 58 patients (81.7%) 1 month after liver transplantation. Twelve patients (16.9%) remained with thrombocytopenia 1 year after liver transplantation. Three patients (4.2%) had recurrence of thrombocytopenia within 1 year after liver transplantation. There was no correlation between pretransplant platelet count and the Child-Pugh class or the MELD score. CONCLUSION: Liver transplantation reverses hypersplenism in most patients.