Experiences of microsurgical reconstruction for variant hepatic artery in living donor liver transplantation

A Systematic Review and Meta-Analysis: Do We Still Need Microscope Surgery in Hepatic Artery Anastomosis to Decrease the Incidence of Complications in Living Donor Liver Transplantation?

Hepatic artery thrombosis (HAT) is the most serious vascular complication after liver transplantation (LT). Moreover, in comparison to deceased donor liver transplantation (DDLT), hepatic artery (HA) anastomosis is more challenging in living donor liver transplantation (LDLT) with a lot of controversial topics about the use of microscopic surgery. We aimed to compare the use of microscopic and loupe surgery in HA anastomosis in adult and pediatric LDLT to decrease the incidence of vascular complications. We searched PubMed, Scopes, Web of Science, and Cochrane Library for eligible studies from inception to April 2023 and a systematic review and a meta-analysis were done. According to our eligibility criteria, 10 studies with a total of 1939 patients were included. In comparison to microscopic surgery, loupe anastomosis has a similar incidence of HAT (thrombosis, risk ratio (RR) = 0.96, 95% CI = 0.26-3.48, P = 0.95). In addition to that, no significant difference was detected between the two types in terms of stenosis, decreased blood flow and hospital stay (decreased blood flow, RR = 0.68, 95% CI = 0.01-86.65, P = 0.88), (stenosis, RR = 1.81, 95% CI = 0.19-17.21, P = 0.60), (hospital stay, mean deviation (MD) = 1.16, 95% CI = -3.79-6.11, P = 0.65). However, the anastomotic time was longer in the case of microscopic surgery (anastomotic time, MD = 24.09, 95% CI = 7.79-40.39, P = 0.004). With an equal incidence of complications and longer anastomotic time, there is no added benefit of the routine use of microscopic surgery in HA anastomosis in LDLT.

Anatomic Variations of the Hepatic Artery in 5625 Patients

Purpose

To analyze the origin and anatomic course of the hepatic arteries by using digital subtraction angiography (DSA) and multidetector CT in a large study sample.

Materials and Methods

This retrospective study included 5625 patients who underwent liver CT and chemoembolization between January 2005 and December 2018 (mean age, 60 years ± 11 [range, 11-99 years]; 4464 males). The CT and DSA images were reviewed to evaluate the visceral arterial anatomy for variations in the celiac axis and hepatic arteries. Aberrant right hepatic arteries (aRHAs) and aberrant left hepatic arteries (aLHAs) were defined on the basis of their origin and anatomic course. Statistical analyses were performed to evaluate the association between aRHAs and aLHAs and the association between variations in the hepatic artery and celiac axis.

Results

Right hepatic arteries were categorized as being aRHAs (if originating from the proximal to middle common hepatic artery, gastroduodenal artery, superior mesenteric artery [SMA], celiac axis, aorta, splenic artery, or left gastric artery [LGA]) or as being aLHAs (if arising from the LGA, celiac axis, aorta, or SMA). The prevalence of aRHAs (15.63%; 879 of 5625) and the prevalence aLHAs (16.32%; 918 of 5625) were similar. Patients with an aRHA were more likely to have an aLHA than those without an aRHA (29.01% vs 13.97%; P < .001), and patients with an aLHA were more likely to have an aRHA than those without an aLHA (27.78% vs 13.26%; P < .001). There was no association between the hepatic arterial variations and celiac axis variations. A hypothetical anatomic model summarizing the observed variations was created.

Conclusion

A comprehensive list of hepatic arterial variations and a three-dimensional hypothetical model for the observed variations were described.Keywords: CT, Angiography, Liver, Anatomy, Arteries© RSNA, 2021 Supplemental material is available for this article. See also commentary by Sutphin and Kalva in this issue.

Microscope-Assisted Arterial Anastomosis in Adult Living Donor Liver Transplantation: A Systematic Review and Meta-analysis of Outcomes

BACKGROUND

 Living donor liver transplantation (LDLT) has expanded the availability of liver transplant but has been associated with early technical complications including the devastating complication of hepatic artery thrombosis (HAT), which has been reported to occur in 14% to 25% of LDLT using standard anastomotic techniques. Microvascular hepatic artery reconstruction (MHAR) has been implemented in an attempt to decrease rates of HAT. The purpose of this study was to review the available literature in LDLT, specifically related to MHAR to determine its impact on rates of posttransplant complications including HAT.

METHODS

 A systematic review was conducted using PubMed/Medline and Web of Science. Case series and reviews describing reports of microscope-assisted hepatic artery anastomosis in adult patients were considered for meta-analysis of factors contributing to HAT.

RESULTS

 In all, 462 abstracts were screened, resulting in 20 studies that were included in the meta-analysis. This analysis included 2,457 patients from eight countries. The pooled rate of HAT was 2.20% with an overall effect size of 0.00906.

CONCLUSION

 Systematic literature review suggests that MHAR during LDLT reduces vascular complications and improves outcomes posttransplant. Microvascular surgeons and transplant surgeons should collaborate when technical challenges such as small vessel size, short donor pedicle, or dissection of the recipient vessel wall are present.

Revascularization of iatrogenic intraoperative injury to a major artery during hepatobiliary-pancreatic surgery: a single-center experience in China

BACKGROUND

Although uncommon during hepatobiliary-pancreatic (HBP) surgery, iatrogenic intraoperative injury to a major artery requires prompt and appropriate repair. Here, we outline our surgical experience with the repair of this injury and compare our experience to findings garnered from a selective review of the literature.

METHODS

We retrospectively analyzed the clinical diagnoses, surgical methods, sites of arterial injury, operative repair, intra-operative blood loss, blood transfusion requirements, postoperative management and outcome of 17 consecutive patients who sustained iatrogenic intra-operative injuries to major arteries during HBP surgery between January 2008 and December 2013.

RESULTS

Depending on the location and extent of injury, suture repair, primary end-to-end anastomosis, artery transposition, interposition grafting, or arterio-portal shunting were used. Postoperative morbidity occurred in three cases and there was only one case of in-hospital mortality (5.9%). No arterial thrombosis or other repair-related complications were found after the operation with a follow-up duration of 6 months.

CONCLUSIONS

The use of an optimal repair method for injured arteries based on their location and extent resulted in a satisfactory outcome.

Usefulness of microsurgical back-table angioplasty for multiple hepatic arteries in living donor liver transplantation

The graft hepatic artery orifice is tiny in living donor liver transplantation, and therefore, it is more difficult to reconstruct the hepatic artery than in deceased donor liver transplantation. In situ, multi-vessel hepatic artery reconstruction in living donor liver transplantation is time-consuming, and reconstructions are often complicated if the hepatic graft has several stumps. We describe two living donor liver transplants using back-table microsurgical angioplasty to combine two hepatic artery stumps to create a single orifice, and sequential single-vessel hepatic artery reconstruction in the recipient. Briefly, we used double-needle interrupted sutures for the two hepatic artery stumps with a biangular stay-suture method in back-table microsurgical angioplasty. Each suture was placed from the inner side of the arterial wall to the outer side, which allowed for safe and reliable suturing. After placing the interrupted sutures in the anterior wall, we turned over the vessels in the cold storage on the back table and placed interrupted sutures in the posterior wall. In the recipient, the single stump of the graft was anastomosed to the recipient's hepatic artery using an interrupted pattern and a surgical microscope. The postoperative courses of the donors and recipients were uneventful. Back-table hepatic artery angioplasty is a feasible option to overcome the complexities of multi-vessel arterial reconstruction in living donor liver transplantation. We recommend performing secure multi-vessel hepatic arterial reconstruction adapted to the clinical scenario. Using simple appropriate anastomosis, back-table microsurgical angiography may provide good results in living donor liver transplantation.

Logistic Coordination in Pediatric Liver Transplantation: Criteria for Optimization

INTRODUCTION

Logistic organization of the transplantation coordination process aims to synchronize the recovery and recipient team and to reduce to a minimum the graft's cold ischemia time (CIT), which, in turn, is known, to have deleterious effects on the graft and recipient, if prolonged. To determine whether variables influencing the different steps in the coordination process might allow for reducing CIT, this study aimed to analyze these variables.

PATIENTS AND METHODS

Retrospective analysis of 61 pediatric liver transplantations from 2006 to 2015 in the Geneva University Hospitals.

RESULTS

Length of donor hepatectomy was increased for split grafts (P < .0001). Length of recipient hepatectomy was longer in the case of previous surgery (P = .06). The recipient team waiting time for the graft was longer for split grafts (P = .01). The graft waiting time at the recipient site was longer for whole grafts (P = .0005) and increased recipient weight (P = .03). The graft waiting time at the donor site was doubled in the case of recovery of organs after the liver by the same team (P = .007). The graft waiting time at the donor and recipient site not surprisingly increased the CIT (P = .007 and < .0001, respectively).

CONCLUSION

CIT depends on waiting times during the entire coordination process, which largely depends on the estimation of hepatectomy lengths. A more accurate estimation, considering graft type and recipient's previous surgery and weight, might allow for decreasing CIT and consequently improve outcomes after pediatric liver transplantation.

Application of a Gastroduodenal Artery Graft for Reconstruction of the Hepatic Artery during Radical Resection of Hilar Cholangiocarcinoma

This paper was designed to evaluate a novel surgical procedure of using a gastroduodenal artery graft for reconstruction of the hepatic artery during radical resection of hilar cholangiocarcinoma, which is citation-free and self-contained. In this paper we retrospectively analyzed the clinical data, surgical procedure, and follow-up results in nine patients who underwent hepatic artery reconstruction using a gastroduodenal artery graft during their radical resection of hilar cholangiocarcinoma and no artery thrombosis or other surgical complications were found after operation with minimum follow-up duration of three months. We recommended that a gastroduodenal artery graft was shown to be a good choice for hepatic artery resection after radical resection of hilar cholangiocarcinoma.