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Herrero A, Souche R, Panaro F, Navarro F. Endovascular balloon occlusion during reconstruction of portal vein injury. Langenbecks Arch Surg 2020; 405:391-395. [PMID: 32361778 DOI: 10.1007/s00423-020-01886-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/22/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Repair of portal vein injury in a hostile abdomen can be very challenging, complicated by massive hemorrhage or stenosis. It can seldom be successfully carried out, even by experienced hepatobiliary surgeons. The ideal venous clamping technique is often not feasible and increases the risk of lethal portal vein laceration. The common mistake being the forceful use of clamps around the vein in the attempt to obtain vascular control, resulting in additional injuries. METHODS We provide a descriptive report of two cases detailing a careful step-by-step technique for the management of portal vein injury by inserting an endovascular balloon inflated with serum to control bleeding and repair the vein. RESULTS In patients who required this technique, no bleeding recurrence, nor portal vein thrombosis or stenosis was detected by CT-scan during follow-up. CONCLUSION The endovascular balloon occlusion technique for the reconstruction of portal vein injuries in hostile abdomen is a safe and life-saving procedure that should be part of the armamentarium of visceral surgeons.
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Affiliation(s)
- Astrid Herrero
- Department of Digestive Surgery and Transplantation, Montpellier University Hospital, University of Montpellier-Nîmes, 641 avenue du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Regis Souche
- Department of Digestive Surgery and Transplantation, Montpellier University Hospital, University of Montpellier-Nîmes, 641 avenue du Doyen Gaston Giraud, 34090, Montpellier, France.
- Department of Digestive Surgery and Transplantation, Saint Eloi Hospital, 80 avenue Augustin Fliche, 34295, Montpellier, France.
| | - Fabrizio Panaro
- Department of Digestive Surgery and Transplantation, Montpellier University Hospital, University of Montpellier-Nîmes, 641 avenue du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Francis Navarro
- Department of Digestive Surgery and Transplantation, Montpellier University Hospital, University of Montpellier-Nîmes, 641 avenue du Doyen Gaston Giraud, 34090, Montpellier, France
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Ikegami T, Yoshizumi T, Iseda N, Toshima T, Elshawy ME, Mori M. Reply. Liver Transpl 2020; 26:463-464. [PMID: 31838772 DOI: 10.1002/lt.25702] [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: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Norifumi Iseda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeo Toshima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mohamed Elemam Elshawy
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masaki Mori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Akbulut S, Yilmaz S. Extensive Thrombectomy as a Legitimate Strategy in Living Donor Liver Transplantation With Advanced Portal Vein Thrombosis. Liver Transpl 2020; 26:461-462. [PMID: 31782604 DOI: 10.1002/lt.25691] [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: 10/31/2019] [Accepted: 11/07/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Sami Akbulut
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Sezai Yilmaz
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya, Turkey
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Ikegami T, Yoshizumi T, Tsutsui Y, Harada N, Itoh S, Yoshiya S, Imai D, Uchiyama H, Mori M. Extensive Thrombectomy as a Legitimate Strategy in Living Donor Liver Transplantation With Advanced Portal Vein Thrombosis. Liver Transpl 2019; 25:1768-1777. [PMID: 31408578 DOI: 10.1002/lt.25623] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/05/2019] [Indexed: 12/12/2022]
Abstract
Management of portal vein thrombosis (PVT), especially advanced PVT involving the superior mesenteric vein (SMV), in living donor liver transplantation (LDLT) is challenging. There were 514 adults who underwent LDLT between 2005 and 2018 included in this retrospective study, and PVT was observed in 67 (13.0%) patients. The LDLT recipients with PVT were characterized by increased portal pressure at laparotomy (26.1 ± 6.0 versus 24.3 ± 5.9 mm Hg; P = 0.03) and at closure (16.8 ± 3.9 versus 15.6 ± 3.6 mm Hg; P = 0.02), increased operative blood loss (14.6 ± 29.7 versus 5.7 ± 6.3 L; P < 0.01), and decreased 1-year graft survival (83.5% versus 92.8%; P = 0.04). Among the 18 patients with atrophic or vanished portal vein on pre-LDLT computed tomography, significant portal atrophy was actually observed only in 1 (5.6%) patient during LDLT surgery. For advanced PVT (n = 7) involving SMV in era 1, we performed nonanatomical inflow reconstruction using interposition grafts, resulting in significant inflow problems in 4 (57.1%) patients. Thus, for the patients with advanced PVT (n = 4) in era 2, we abandoned nonanatomical reconstruction and applied extensive thrombectomy under ultrasound guidance with secure shunt ligation, resulting in no inflow problems and no graft loss. In conclusion, even for advanced PVT involving SMV, extensive thrombectomy under sonogram guidance followed by anatomical inflow reconstruction and shunt ligation is a legitimate strategy in adult LDLT with PVT.
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Affiliation(s)
- Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuriko Tsutsui
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noboru Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shohei Yoshiya
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Imai
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hideaki Uchiyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masaki Mori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Soejima Y, Yoshizumi T, Ikegami T, Harimoto N, Harada N, Itoh S, Toshima T, Motomura T, Mano Y, Ohira M, Bekki Y, Maehara Y. Real-Time Ultrasound-Guided Thrombectomy for Extensive Portal Vein Thrombosis in Living Donor Liver Transplantation. Transplant Proc 2018; 50:3549-3551. [DOI: 10.1016/j.transproceed.2018.08.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/24/2018] [Accepted: 08/16/2018] [Indexed: 10/28/2022]
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Seal JB, Bohorquez H, Battula N, DeGregorio L, Bugeaud E, Bruce DS, Carmody IC, Cohen AJ, Loss GE. Balloon-Occlusion Technique for Managing Portal Vein Hemorrhage in Liver Transplantation. Ochsner J 2017; 17:76-79. [PMID: 28331452 PMCID: PMC5349641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) is relatively common among candidates for liver transplantation and can present significant intraoperative challenges. Depending on the extent of PVT, thromboendovenectomy (TEV), portal bypass, or systemic inflow may be required to restore portal inflow. While TEV is the most commonly used approach to restore anatomic portal inflow, portal vein injury and life-threatening hemorrhage are risks with this technique. CASE REPORT We present a salvage technique for managing portal vein injury during TEV using intraluminal balloon occlusion of the portal vein during portal vein repair and reconstruction. This alternative mode of bleeding control optimizes exposure to the retropancreatic space and avoids direct application of vascular clamps that can cause further injury to the vessel and surrounding tissue. CONCLUSION Careful preoperative planning and anticipation of potential problems are essential for safe and effective management of complex PVT intraoperatively. The balloon-occlusion technique can facilitate safe and efficient repair of a portal vein injury during TEV for liver transplantation.
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Affiliation(s)
- John B. Seal
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Humberto Bohorquez
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Naren Battula
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Lucia DeGregorio
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Emily Bugeaud
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - David S. Bruce
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Ian C. Carmody
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Ari J. Cohen
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - George E. Loss
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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Huang CM, Chen RF, Chen QY, Wei J, Zheng CH, Li P, Xie JW, Wang JB, Lin JX, Lu J, Cao LL, Lin M. Application Value of a 6-Type Classification System for Common Hepatic Artery Absence During Laparoscopic Radical Resections for Gastric Cancer: A Large-Scale Single-Center Study. Medicine (Baltimore) 2015; 94:e1280. [PMID: 26266363 PMCID: PMC4616714 DOI: 10.1097/md.0000000000001280] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The common hepatic artery (CHA) is an important blood vessel that must be vascularized during D2 lymphadenectomies for gastric cancer. When the CHA is absent, the risk of vascular injury increases.To explore the anatomic classification of CHA absence and its application value in laparoscopic radical resections for gastric cancer.Clinical data were collected prospectively from 2170 gastric cancer patients from June 2007 to December 2013, and the data were analyzed retrospectively. The anatomy of CHA absence was assessed synthetically by combining preoperative CT scans and intraoperative images, which were classified according to the anatomy of replaced hepatic arteries (RHAs) and were grouped into the early-year group (2007-2011) and the later-year group (2012-2013) based on the year in which the operation was performed.CHA absence was noted in 38 cases (1.8%) and was classified into 6 types: type I (replaced CHA [RCHA] from the superior mesenteric artery [SMA] with retropancreatic course, 28), type II (RCHA from the SMA with circumambulated course, 1), type III (RCHA from the aortic artery, 1), type IV (replaced left hepatic artery [RLHA] from the left gastric artery [LGA] and replaced right hepatic artery [RRHA] from the SMA, 5), type V (RLHA from the LGA and RRHA from the celiac artery, 2), and type VI (RLHA from the aberrant gastroduodenal artery and RRHA from the SMA, 1). Of the 38 cases, 17 cases (44.7%) belong to the early-year group, and 21 cases (55.3%) belong to the later-year group. The vascular injury rate was significantly lower in the later-year group than in the early-year group (4.8% [1/21] vs 41.2% [7/17], P = 0.005]. Additionally, the alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBIL) values were significantly lower in the later-year group than in the early-year group on postoperative day 3 (all P < 0.05).A 6-type anatomic classification system can be used to demonstrate variations in features resulting from CHA absence in detail. Knowledge regarding a patient's classification is helpful for surgeons, and vascular injury and liver function damage may be reduced in patients who are properly classified prior to surgery.
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Affiliation(s)
- Chang-Ming Huang
- From the Department of Gastric Surgery (C-MH, R-FC, Q-YC, C-HZ, PL, J-WX, J-BW, J-XL, JL, L-LC, ML); and Department of CT/MR, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China (JW)
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