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Pan B, Liu W, Ou YJ, Zhang YQ, Jiang D, Li YC, Chen ZY, Zhang LD, Zhang CC. Gastroduodenal artery disconnection during liver transplantation decreases non-anastomotic stricture incidence. Hepatobiliary Pancreat Dis Int 2023; 22:28-33. [PMID: 36210313 DOI: 10.1016/j.hbpd.2022.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/23/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The hepatic artery is the only blood source nourishing the biliary duct and associated with biliary complication after liver transplantation (LT). Gastroduodenal artery (GDA) disconnection increased proper hepatic artery flow. Whether this procedure attenuates biliary non-anastomotic stricture (NAS) is not clear. METHODS A total of 241 patients with LT were retrospectively analyzed. The patients were divided into the GDA disconnection (GDA-) and GDA preservation (GDA+) groups. Propensity score matching (PSM) was administrated to reduce bias. Logistic regression was conducted to analyze risk factors for biliary NAS before and after PSM. Postoperative complications were compared. Kaplan-Meier survival analysis and log-rank tests were performed to compare overall survival. RESULTS In all, 99 patients (41.1%) underwent GDA disconnection, and 49 (20.3%) developed NAS. Multivariate logistic regression revealed that GDA preservation (OR = 2.24, 95% CI: 1.11-4.53; P = 0.025) and model for end-stage liver disease (MELD) score > 15 (OR = 2.14, 95% CI: 1.12-4.11; P = 0.022) were risk factors for biliary NAS. PSM provided 66 pairs using 1:2 matching method, including 66 GDA disconnection and 99 GDA preservation patients. Multivariate logistic regression after PSM also showed that GDA preservation (OR = 3.15, 95% CI: 1.26-7.89; P = 0.014) and MELD score > 15 (OR = 2.41, 95% CI: 1.08-5.36; P = 0.031) were risk factors for NAS. When comparing complications between the two groups, GDA preservation was associated with a higher incidence of biliary NAS before and after PSM (P = 0.031 and 0.017, respectively). In contrast, other complications including early allograft dysfunction (P = 0.620), small-for-size graft syndrome (P = 0.441), abdominal hemorrhage (P = 1.000), major complications (Clavien-Dindo grade ≥ 3, P = 0.318), and overall survival (P = 0.088) were not significantly different between the two groups. CONCLUSIONS GDA disconnection during LT ameliorates biliary NAS incidence and may be recommended for application in clinical practice.
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Affiliation(s)
- Bi Pan
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Wei Liu
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yan-Jiao Ou
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yan-Qi Zhang
- Department of Health Statistics, College of Military Preventive Medicine, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Di Jiang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yuan-Cheng Li
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Zhi-Yu Chen
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Lei-Da Zhang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Cheng-Cheng Zhang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
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Seifert L, von Renesse J, Seifert AM, Sturm D, Meisterfeld R, Rahbari NN, Kahlert C, Distler M, Weitz J, Reissfelder C. Interrupted versus continuous suture technique for biliary-enteric anastomosis: randomized clinical trial. BJS Open 2023; 7:7021143. [PMID: 36723996 PMCID: PMC9891343 DOI: 10.1093/bjsopen/zrac163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/27/2022] [Accepted: 11/05/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Biliary-enteric anastomosis (BEA) can be performed using continuous or interrupted suture techniques, but high-quality evidence regarding superiority of either technique is lacking. The aim of this study was to compare the suture techniques for patients undergoing BEA by evaluating the suture time as well as short- and long-term biliary complications. METHODS In this single-centre randomized clinical trial, patients scheduled for elective open procedure with a BEA between 21 January 2016 and 20 September 2017 were randomly allocated in a 1:1 ratio to have the BEA performed with continuous suture (CSG) or interrupted suture technique (ISG). The primary outcome was the time required to complete the anastomosis. Secondary outcomes were BEA-associated postoperative complications with and without operative revision of the BEA, including bile leakage, cholestasis, and cholangitis, as well as morbidity and mortality up to day 30 after the intervention and survival. RESULTS Altogether, 82 patients were randomized of which 80 patients received the allocated intervention (39 in ISG and 41 in CSG). Suture time was longer in the ISG compared with the CSG (median (interquartile range), 22.4 (15.0-28.0) min versus 12.0 (10.0-17.0) min, OR 1.26, 95 per cent c.i. 1.13 to 1.40; unit of increase of 1 min; P < 0.001). Short-term and long-term biliary complications were similar between groups. The incidence of bile leakage (6 (14.6 per cent) versus 4 (10.3 per cent), P = 0.738) was comparable between groups. No anastomotic stenosis occurred in either group. CONCLUSION Continuous suture of BEA is equally safe, but faster compared with interrupted suture. REGISTRATION NUMBER NCT02658643 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Lena Seifert
- Correspondence to: Lena Seifert, Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany (e-mail: )
| | - Janusz von Renesse
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Adrian M Seifert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany,National Center for Tumor Diseases (NCT), Partner Site Dresden, Heidelberg, Germany,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Dresden, Heidelberg, Germany
| | - Dorothée Sturm
- Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Ronny Meisterfeld
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Nuh N Rahbari
- Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany,National Center for Tumor Diseases (NCT), Partner Site Dresden, Heidelberg, Germany,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Dresden, Heidelberg, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany,National Center for Tumor Diseases (NCT), Partner Site Dresden, Heidelberg, Germany,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Dresden, Heidelberg, Germany
| | - Christoph Reissfelder
- Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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Fukushima R, Ishii N, Harimoto N, Araki K, Watanabe A, Tsukagoshi M, Hagiwara K, Yamanaka T, Shirabe K. A case of Mirizzi syndrome accompanied by a pseudoaneurysm that ruptured into the gallbladder: successfully treated by embolization of aneurysm and sequential surgery. Surg Case Rep 2022; 8:111. [PMID: 35699820 PMCID: PMC9198164 DOI: 10.1186/s40792-022-01467-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/05/2022] [Indexed: 12/05/2022] Open
Abstract
Background Although visceral aneurysms are relatively rare, it can be life-threatening in case it ruptures. We report a case of Mirizzi syndrome accompanied by a pseudoaneurysm that ruptured into the gallbladder. Case presentation The patient was a 73-year-old woman with persistent gastrointestinal bleeding and progressive jaundice. Examination revealed a pseudoaneurysm in the gallbladder artery or hepatic artery branch, and biliary hemorrhage due to gallbladder perforation was suspected. Urgent abdominal angiography revealed a pseudoaneurysm measuring 50 × 32 mm that had ruptured directly from the right hepatic artery or the cystic artery into the gallbladder. The pseudoaneurysm was successfully coiled and the bleeding was stopped. The presence of ongoing obstruction due to Mirizzi syndrome resulted in an emergency cholecystectomy being performed on the same day. On removing the impacted gallstone from the neck of the gallbladder, we found an obstruction between the lateral wall of the common bile duct and the gallbladder, this condition was diagnosed as Mirizzi syndrome with a biliobiliary fistula. After removing the impacted gallstone, a T-tube was inserted into the common bile duct. Bile leakage was observed postoperatively, but it improved with drainage. The patient fully recovered. Conclusions We present our experience with a case of Mirizzi syndrome accompanied by a ruptured pseudoaneurysm successfully treated with coil embolization followed by cholecystectomy. In this case, the pseudoaneurysm may have been caused by inflammation due to cholecystitis or compression of the arterial wall by a gallstone. To the best of our knowledge, Mirizzi syndrome associated with pseudoaneurysm rupture is rare. Our study suggested that cholecystectomy preceded by transcatheter arterial embolization is an effective strategy to control bleeding in patients with hemobilia due to aneurysm.
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Tomioka A, Asakuma M, Kawaguchi N, Komeda K, Shimizu T, Lee SW. Combined resection of the gastroduodenal artery without revascularization in distal pancreatectomy with en bloc celiac axis resection (extended DP-CAR) for pancreatic cancer: A case report. Int J Surg Case Rep 2022; 102:107803. [PMID: 36493709 PMCID: PMC9730029 DOI: 10.1016/j.ijscr.2022.107803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) is performed to remove locally advanced pancreatic cancer (LAPC) that involves the celiac axis (CA), the common hepatic artery (CHA), or the root of the splenic artery (SpA). It is not usually applied to LAPC involving both the CA and the gastroduodenal artery (GDA) because transection of the GDA cannot assure hepatic perfusion. Preserving the replaced hepatic artery might allow combined resection of the GDA without revascularization. PRESENTATION OF CASE A 78-year-old woman who was diagnosed with LAPC of the pancreatic head and body that invaded the GDA and proper hepatic artery, as well as the CA. The left hepatic artery (LHA) was solitarily branched from the left gastric artery (LGA), which was branched from proximal to the confluence of the CHA and the SpA. The root of the LGA was intact. We successfully performed DP-CAR with combined resection of the GDA, without revascularization, by preserving the LGA. DISCUSSION This is the first English literature case of extended DP-CAR with preservation of the replaced LHA (r-LHA). Aberrant right and left hepatic arteries are common variations. Checking the arterial variations is very important when deciding the treatment strategy for LAPC, especially in cases that appear unresectable. CONCLUSION Our case indicated that the r-LHA alone can supply the entire liver in extended DP-CAR. The resectability must be decided with close evaluations of the vessel variations and the tumor status.
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Affiliation(s)
- Atsushi Tomioka
- General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University.
| | - Mitsuhiro Asakuma
- General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University.
| | - Nao Kawaguchi
- General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University.
| | - Koji Komeda
- General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University.
| | - Tetsunosuke Shimizu
- General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University.
| | - Sang-Woong Lee
- General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University.
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Aramburu J, Antón R, Fukamizu J, Nozawa D, Takahashi M, Ozaki K, Ramos JC, Sangro B, Bilbao JI, Tomita K, Matsumoto T, Hasebe T. In Vitro Model for Simulating Drug Delivery during Balloon-Occluded Transarterial Chemoembolization. BIOLOGY 2021; 10:biology10121341. [PMID: 34943256 PMCID: PMC8698760 DOI: 10.3390/biology10121341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 12/24/2022]
Abstract
Background: Balloon-occluded transarterial chemoembolization (B-TACE) has emerged as a safe and effective procedure for patients with liver cancer, which is one of the deadliest types of cancer worldwide. B-TACE consist of the transcatheter intraarterial infusion of chemotherapeutic agents, followed by embolizing particles, and it is performed with a microballoon catheter that temporarily occludes a hepatic artery. B-TACE relies on the blood flow redistribution promoted by the balloon-occlusion. However, flow redistribution phenomenon is not yet well understood. Methods: This study aims to present a simple in vitro model (IVM) where B-TACE can be simulated. Results: By visually analyzing the results of various clinically-realistic experiments, the IVM allows for the understanding of balloon-occlusion-related hemodynamic changes and the importance of the occlusion site. Conclusion: The IVM can be used as an educational tool to help clinicians better understand B-TACE treatments. This IVM could also serve as a base for a more sophisticated IVM to be used as a research tool.
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Affiliation(s)
- Jorge Aramburu
- Tecnun Escuela de Ingeniería, Universidad de Navarra, 20018 Donostia-San Sebastián, Spain; (R.A.); (J.C.R.)
- Correspondence:
| | - Raúl Antón
- Tecnun Escuela de Ingeniería, Universidad de Navarra, 20018 Donostia-San Sebastián, Spain; (R.A.); (J.C.R.)
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, 31008 Pamplona, Spain; (B.S.); (J.I.B.)
| | - Junichi Fukamizu
- Terumo Corporation, 3-20-2, Nishi-Shinjuku, Shinjuku-ku, Tokyo 163-1450, Japan; (J.F.); (D.N.)
| | - Daiki Nozawa
- Terumo Corporation, 3-20-2, Nishi-Shinjuku, Shinjuku-ku, Tokyo 163-1450, Japan; (J.F.); (D.N.)
| | - Makoto Takahashi
- Terumo Medical Pranex, 1500 Inokuchi, Nakai, Ashigarakami 259-0151, Japan; (M.T.); (K.O.)
| | - Kouji Ozaki
- Terumo Medical Pranex, 1500 Inokuchi, Nakai, Ashigarakami 259-0151, Japan; (M.T.); (K.O.)
| | - Juan Carlos Ramos
- Tecnun Escuela de Ingeniería, Universidad de Navarra, 20018 Donostia-San Sebastián, Spain; (R.A.); (J.C.R.)
| | - Bruno Sangro
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, 31008 Pamplona, Spain; (B.S.); (J.I.B.)
- Liver Unit and CIBEREHD, Clínica Universidad de Navarra, 31008 Pamplona, Spain
| | - José Ignacio Bilbao
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, 31008 Pamplona, Spain; (B.S.); (J.I.B.)
- Department of Radiology, Clínica Universidad de Navarra, 31008 Pamplona, Spain
| | - Kosuke Tomita
- Department of Radiology, Tokai University Hachioji Hospital, Tokai University School of Medicine, 1838 Ishikawa-machi, Hachioji, Tokyo 192-0032, Japan; (K.T.); (T.M.); (T.H.)
| | - Tomohiro Matsumoto
- Department of Radiology, Tokai University Hachioji Hospital, Tokai University School of Medicine, 1838 Ishikawa-machi, Hachioji, Tokyo 192-0032, Japan; (K.T.); (T.M.); (T.H.)
| | - Terumitsu Hasebe
- Department of Radiology, Tokai University Hachioji Hospital, Tokai University School of Medicine, 1838 Ishikawa-machi, Hachioji, Tokyo 192-0032, Japan; (K.T.); (T.M.); (T.H.)
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6
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Marichez A, Turrini O, Fernandez B, Garnier J, Lapuyade B, Ewald J, Adam JP, Marchese U, Chiche L, Delpero JR, Laurent C. Does pre-operative embolization of a replaced right hepatic artery before pancreaticoduodenectomy for pancreatic adenocarcinoma affect postoperative morbidity and R0 resection? A bi-centric French cohort study. HPB (Oxford) 2021; 23:1683-1691. [PMID: 33933344 DOI: 10.1016/j.hpb.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 03/06/2021] [Accepted: 04/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sacrificing a replaced right hepatic artery (rRHA) from the superior mesenteric artery is occasionally necessary to obtain an R0 resection after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). Preoperative embolization (PEA) of the rRHA has been proposed to avoid the onset of postoperative biliary and ischemic liver complications. METHODS Eighteen patients with cephalic PA with an rRHA underwent PEA of the rRHA from 2013 to 2019. The monitoring after embolization and PD was systematic and included a clinical-biological evaluation and a computed tomography scan. This study aimed to determine the feasibility of PEA of the rRHA, postoperative morbidity at 90 days, and quality of oncologic resection after PD. RESULTS Feasibility of PEA was 100% without complications. A PD was performed in 16/18 patients. Mortality was 2/16 with one death after septic shock with hepatic ischemia without an arterial obstruction. Overall morbidity was 44% including one hepatic abscess after hepatic ischemia (6%). Two resections were R1 (<1 mm) in contact with the origin of the rRHA (2/4 R1). CONCLUSION PEA of the rRHA before PD was safe and reproducible. PEA of the rRHA followed by en bloc PD resection seems to limit the risk of bilio-hepatic ischemia and could facilitate oncologic resection.
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Affiliation(s)
- Arthur Marichez
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - Olivier Turrini
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, Marseille, France
| | - Benjamin Fernandez
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - Jonathan Garnier
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, Marseille, France
| | - Bruno Lapuyade
- Department of Radiology, Haut Lévêque, CHU de Bordeaux, Hospital Bordeaux University, Bordeaux, France
| | - Jacques Ewald
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, Marseille, France
| | - Jean-Philippe Adam
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - Ugo Marchese
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, Marseille, France
| | - Laurence Chiche
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France; Department of Research, INSERM UMR 1035, CHU Bordeaux, France
| | - Jean-Robert Delpero
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, Marseille, France
| | - Christophe Laurent
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France; Department of Research, INSERM UMR 1035, CHU Bordeaux, France.
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Egorov VI, Petrov RV, Amosova EL, Kharazov AF, Petrov KS, Zhurina YA, Kondratyev EV, Zelter PM, Dzigasov SO, Grigorievsky MV. [Distal pancreatectomy with resection of the celiac trunk, right or left hepatic artery without arterial reconstruction (extended DP-CAR)]. Khirurgiia (Mosk) 2021:13-28. [PMID: 34608776 DOI: 10.17116/hirurgia202110113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate safety and postoperative outcomes of DP-CAR with resection of one of the lobar hepatic arteries without arterial reconstruction (extended DP-CAR). MATERIAL AND METHODS Perioperative data and survival after 7 extended DP-CARs R0 were retrospectively analyzed. Arterial blood flow in the liver was assessed using intraoperative ultrasound and postoperative CT angiography. RESULTS Among 40 DP-CARs, resection of left or right hepatic artery was performed in 7 cases of aberrant anatomy including 1 case of portal vein resection. Mortality and ischemic complications were not observed. The main source of blood supply to the «devascularized» liver lobe was interlobar communicating artery or the arcade of the lesser curvature of the stomach. Incidence of pancreatic fistula was 44%, mean blood loss - 230 (100-650) ml, surgery time - 259 (195-310) min, mean hospital-stay - 14 (9-26) days. Median survival of patients with pancreatic ductal adenocarcinoma was 25 months after combined treatment. Three patients died after 26, 28 and 77 months. Other patients are alive without progression for 109, 24, 23 and 12 months after therapy onset. CONCLUSION Extended DP-CAR is advisable and safe procedure if reliable intraoperative control of liver and stomach blood supply is ensured.
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Affiliation(s)
- V I Egorov
- Ilyinskaya Hospital, Krasnogorsk, Russia
| | - R V Petrov
- Ilyinskaya Hospital, Krasnogorsk, Russia
| | | | - A F Kharazov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | | | | | - E V Kondratyev
- Ilyinskaya Hospital, Krasnogorsk, Russia.,Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - P M Zelter
- Samara State Medical University, Samara, Russia
| | | | - M V Grigorievsky
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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8
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Xu H, Yu X, Hu J. The Risk Assessment and Clinical Research of Bile Duct Injury After Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma. Cancer Manag Res 2021; 13:5039-5052. [PMID: 34234549 PMCID: PMC8253927 DOI: 10.2147/cmar.s303172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/02/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose To retrospectively evaluate the risk factors and the clinical outcomes of bile duct injury after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) and to evaluate factors that aid clinical detection and subsequent treatment of the injured bile duct. Materials and Methods All patients undergoing TACE for HCC were retrospectively reviewed for identification of bile duct injury. The clinical spectrum of all the patients analyzed including patients’ demographics, laboratory data, radiologic imaging and mode of treatment. Results From January 2015 to December 2017, a total of 21 patients (4.3%) out of 483 patients with 693 TACE procedures were identified to have bile duct injury at our single institution. There were 17 males and 4 females, with a mean age of 59.8±11.6 years (range 34–84). About 14.3% (3/21) patients show the high-density shadow around the bile duct wall in one week non-enhanced CT, and 76.2% (16/21) cases ALP>200 U/L, all these patients showed bile duct injury on the subsequent follow-up CT. Post-TACE follow-up blood biochemistry showed that alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GGT) increased significantly compared with pre-TACE level. The incidence of various types of bile duct injuries on CT was intrahepatic bile duct dilatation (57.1%), biloma (25.7%) and hepatic hilar biliary strictures (17.1%), respectively. Patients with prior hepatectomy as well as proximal arterial chemoembolization carried a higher risk of post-TACE bile duct injury in terms of microvascular damage to the peribiliary capillary plexus. Conclusion Bile duct injury complicating TACE is not caused by a single factor, but by a variety of factors, and is closely related to the microvascular compromise of the bile ducts and subsequent chronic biliary infection. Lipiodol deposited along the bile duct wall and the sharp rise of ALP>200 U/L in one week after TACE can predict bile duct injury and early intervention may prevent the occurrence of serious complications. The probability of bile duct injury in patients with prior hepatectomy and proximal arterial chemoembolization increases significantly.
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Affiliation(s)
- Houyun Xu
- Department of Radiology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, People's Republic of China
| | - Xiping Yu
- Department of Pathology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu,People's Republic of China
| | - Jibo Hu
- Department of Radiology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, People's Republic of China
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9
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Burasakarn P, Higuchi R, Yazawa T, Uemura S, Izumo W, Matsunaga Y, Yamamoto M. Hepatic artery resection without reconstruction in pancreatoduodenectomy. Langenbecks Arch Surg 2021; 406:2081-2090. [PMID: 33932159 DOI: 10.1007/s00423-021-02178-w] [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: 07/10/2020] [Accepted: 04/18/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE It has been reported that there are left and right hepatic arterial arcades via the blood vessels around the hilar bile duct; therefore, when the hilar bile duct is preserved, hepatic artery reconstruction may not be necessary. We compared the short-term and long-term outcomes in patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy (PD) with right hepatic artery resection without right hepatic artery reconstruction (RHAR group) with those patients who underwent conventional PD. METHODS All data were retrospectively collected from patient records. A 1:4-propensity score-matched case-control study was conducted in patients with distal cholangiocarcinoma who received treatment at Tokyo Women's Medical University from February 1985 to April 2015. RESULTS There was no statistical difference in the overall morbidity rate between the two groups. No patient in the RHAR group (10 patients) had liver failure, liver abscess, or cholangitis in the postoperative period; one patient died postoperatively because of a bleeding pseudoaneurysm in the gastroduodenal artery. The PD group (40 patients) had a significantly better median time regarding the recurrence (34 vs. 11 months, p=0.027) and 5-year disease-free survival (35% vs. 10%, p=0.027) rates than the RHAR group, which may be attributed to the presence of a more severe disease in patients in the RHAR group. CONCLUSION We concluded that pancreaticoduodenectomy with right hepatic artery resection without reconstruction has a comparable overall morbidity rate with that of a conventional pancreaticoduodenectomy surgery and may be performed as an alternative procedure when tumor invasion of the right hepatic artery is suspected.
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Affiliation(s)
- Pipit Burasakarn
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.,Division of HPB Surgery, Department of Surgery, Phramongkutklao Hospital, Bangkok, Thailand
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Takehisa Yazawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shuichiro Uemura
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Wataru Izumo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yutaro Matsunaga
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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10
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Anatomical Basis for Selective Multiple Arterial Reconstructions in Living Donor Liver Transplantation. Langenbecks Arch Surg 2021; 406:1943-1949. [DOI: 10.1007/s00423-021-02176-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 04/12/2021] [Indexed: 01/16/2023]
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11
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Video review reveals technical factors predictive of biliary stricture and cholangitis after robotic pancreaticoduodenectomy. HPB (Oxford) 2021; 23:144-153. [PMID: 32646806 DOI: 10.1016/j.hpb.2020.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/13/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cholangitis due to anastomotic stricture of the hepaticojejunostomy (HJ) following pancreaticoduodenectomy (PD), while uncommon, adversely affects postoperative quality-of-life. While prior studies have identified patient-related risk factors for these biliary complications, technical risk factors have not been systematically examined. Video review of surgical procedures has helped define technical details predictive of postoperative complications in bariatric and hepato-pancreato-biliary (HPB) surgery. Similarly, the present study utilized video review to identify technical factors associated with cholangitis and anastomotic biliary stricture following robotic PD. METHODS This was an observational study. A blinded experienced HPB surgeon reviewed videos of post-learning-curve HJs performed during robotic PD and extracted 20 technical variables. Other demographic and clinical variables were collected from a prospectively maintained database. RESULTS 241 robotic PD videos were reviewed. 29 (12.0%) developed cholangitis and/or biliary stricture, with a median time-to-event of 189 (IQR 78-365) days. Several clinical and technical factors were independently predictive of cholangitis and/or biliary stricture: preoperative radiotherapy, small duct size (<10 mm diameter), increased distance of the HJ (>10 mm) from the hilar plate, and continuous suturing technique. CONCLUSION Post-hoc video review of HJ is a powerful method to predict biliary complications. Moreover, altering specific technical factors might enable surgeons to improve postoperative outcomes.
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12
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Xu Y, Chen M, Meng X, Lu P, Wang X, Zhang W, Luo Y, Duan W, Lu S, Wang H. Laparoscopic anatomical liver resection guided by real-time indocyanine green fluorescence imaging: experience and lessons learned from the initial series in a single center. Surg Endosc 2020; 34:4683-4691. [PMID: 32500459 DOI: 10.1007/s00464-020-07691-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/27/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Anatomical liver resection is an established procedure for primary hepatic tumors. Laparoscopic anatomical hepatectomy has been proven to be technically achievable from S1 to S8 in experienced hands. The indocyanine green (ICG) fluorescence imaging technique offers a novel tool of intraoperative visualization in hepatobiliary surgery. This study aims to investigate the feasibility of laparoscopic anatomical liver resection based on segmental staining using real-time ICG fluorescence. METHODS From December 2015 to October 2017, 36 patients in our institute underwent lap-ALR using real-time ICG fluorescence mapping of the tumor-bearing portal territory. The procedural and perioperative data were collected and analyzed. RESULTS In our case series, we successfully performed the fashion of positive staining mostly in segmentectomy or sub-segmentectomy by individually injecting 5-10 ml of ICG (0.025 mg/ml) into its feeding portal branch guided by intraoperative ultrasound, and the negative staining mainly for sectionectomy, hemihepatectomy and multi-segmentectomy by interrupting the Glissonean pedicle serving the tumor-bearing segments and systemically injecting 1 ml of ICG (2.5 mg/ml). Our total successful rate of staining is 53%. No conversion to laparotomy, Clavien III-IV complication or 90-day mortality occurred. Valuable technical feedback, experience and lessons are learned from this initial practice. CONCLUSIONS Real-time ICG fluorescence imaging adds much precision to laparoscopic anatomical hepatectomy. The success of segmental staining requires a high proficiency of IOUS and skillful interpretation of preoperative 3D simulation. Decision-making on the fashions of positive and negative staining have been initially recommended. Multi-centered practice and technical modification are necessary to standardize its application.
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Affiliation(s)
- Yinzhe Xu
- Department of Hepatobiliary Surgery, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Mingyi Chen
- Department of Hepatobiliary Surgery, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Xiangfei Meng
- Department of Hepatobiliary Surgery, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Peng Lu
- Department of Hepatobiliary Surgery, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Xun Wang
- Department of Hepatobiliary Surgery, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Wenwen Zhang
- Department of Hepatobiliary Surgery, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Ying Luo
- Department of Hepatobiliary Surgery, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Weidong Duan
- Department of Hepatobiliary Surgery, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Shichun Lu
- Department of Hepatobiliary Surgery, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China.
| | - Hongguang Wang
- Department of Hepatobiliary Surgery, First Medical Center, Chinese PLA General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China.
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13
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Kuribara T, Ichikawa T, Osa K, Inoue T, Ono S, Asanuma K, Kaneko S, Sano T, Shigeyoshi I, Matsubara K, Irie N, Iai A, Shinobi T, Ishizu H, Miura K. Combined resection of the hepatic artery without reconstruction in pancreaticoduodenectomy: a case report of pancreatic cancer with an aberrant hepatic artery. Surg Case Rep 2020; 6:228. [PMID: 32990830 PMCID: PMC7524997 DOI: 10.1186/s40792-020-00997-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/18/2020] [Indexed: 12/22/2022] Open
Abstract
Background Pancreaticoduodenectomy (PD) is rarely performed for pancreatic cancer with hepatic arterial invasion owing to its poor prognosis and high surgical risks. Although there has been a recent increase in the reports of PD combined with hepatic arterial resection due to improvements in disease prognosis and operative safety, PD with major arterial resection and reconstruction is still considered a challenging treatment. Case presentation A 61-year-old man with back pain was diagnosed with pancreatic head and body cancer. Although distant metastasis was not confirmed, the tumor had extensively invaded the hepatic artery; therefore, we diagnosed the patient with locally advanced unresectable pancreatic cancer. After gemcitabine plus nab-paclitaxel (GnP) therapy, the tumor considerably decreased in size from 35 to 20 mm. Magnetic resonance imaging revealed a gap between the tumor and the hepatic artery. Tumor marker levels returned to their normal range, and we decided to perform conversion surgery. In this case, an artery of liver segment 2 (A2) had branched from the left gastric artery; therefore, we decided to preserve A2 and perform PD combined with hepatic arterial resection without reconstruction. After four cycles of GnP therapy, we performed hepatic arterial embolization to prevent postoperative ischemic complications prior to surgery. Immediately after embolization, collateral arterial blood flow to the liver was observed. Operation was performed 19 days after embolization. Although there was a temporary increase in liver enzyme levels and an ischemic region was found near the surface of segment 8 of the liver after surgery, no liver abscess developed. The postoperative course was uneventful, and S-1 was administered for a year as adjuvant chemotherapy. The patient is currently alive without any ischemic liver events and cholangitis and has not experienced recurrence in the past 4 years since the surgery. Conclusions In PD for pancreatic cancer with hepatic arterial invasion, if a part of the hepatic artery is aberrant and can be preserved, combined resection of the common and proper hepatic artery without reconstruction might be feasible for both curability and safety.
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Affiliation(s)
- Tadao Kuribara
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan.
| | - Tatsuo Ichikawa
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Kiyoshi Osa
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Takeshi Inoue
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Satoshi Ono
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Kozo Asanuma
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Shiori Kaneko
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Takayuki Sano
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Itaru Shigeyoshi
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Kouta Matsubara
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Naoko Irie
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Akira Iai
- Department of Surgery, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, 333-0831, Japan
| | - Tetsuya Shinobi
- Department of Internal Medicine, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, Japan
| | - Hideki Ishizu
- Department of Pathology, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, Japan
| | - Katsuhiro Miura
- Department of Internal Medicine, Saitama Cooperative Hospital, 1317 Kizoro, Kawaguchi-shi, Saitama, Japan.,Tumor Center, Nihon University Itabashi Hospital, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo, Japan.,Department of Hematology and Rheumatology, Nihon University School of Medicine, 30-1, Oyaguchikamicho, Itabashi-ku, Tokyo, Japan
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14
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Kwon J, Shin SH, Yoo D, Hong S, Lee JW, Youn WY, Hwang K, Lee SJ, Park G, Park Y, Lee W, Song KB, Lee JH, Hwang DW, Kim SC. Arterial resection during pancreatectomy for pancreatic ductal adenocarcinoma with arterial invasion: A single-center experience with 109 patients. Medicine (Baltimore) 2020; 99:e22115. [PMID: 32925757 PMCID: PMC7489745 DOI: 10.1097/md.0000000000022115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pancreatectomy for pancreatic cancer with arterial invasion is controversial and performed infrequently. As its indication evolves and neoadjuvant chemotherapy also evolves, it is meaningful to identify short- and long-term outcomes of pancreatectomy with arterial resection (AR). This study aimed to retrospectively analyze the clinical outcomes of pancreatectomy with AR for pancreatic ductal adenocarcinoma.Patients with pancreatic ductal adenocarcinoma treated with pancreatectomy with AR at our institute between January 2000 and April 2017 were retrospectively reviewed. Operative outcome and survival were compared according to the presence of neoadjuvant chemotherapy.This study included 109 patients (38 underwent surgery after neoadjuvant chemotherapy, 71 underwent upfront surgery). The median hospital stay was 17 (interquartile range, 12-26.5) days. Clinically relevant postoperative pancreatic fistula (grade B or C) occurred in 14 patients (12.8%). The major morbidity (≥grade III) and mortality rates were 26.6% and 0.9%, respectively. R0 resection was achieved in 80 patients (73.4%). Microscopic actual tumor invasion into the arterial wall was identified in 25 patients (22.9%). The median overall survival (OS) of all patients was 18.4 months. The neoadjuvant chemotherapy group showed better OS than the upfront surgery group, without statistical significance (25.3 vs 16.2 months, P = .06). Progression-free survival was better in patients with neoadjuvant chemotherapy (13.2 vs 7.1 months, P = .01). Patients with partial response to neoadjuvant chemotherapy showed better OS than those with stable disease (33.7 vs 17.5 months, P = .04).Pancreatectomy with AR for advanced pancreatic cancer showed acceptable procedure-related morbidity and mortality. A survival benefit of neoadjuvant chemotherapy was identified, compared to upfront surgery.
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Affiliation(s)
- Jaewoo Kwon
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Sang Hyun Shin
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Daegwang Yoo
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Sarang Hong
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Jong Woo Lee
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Woo Young Youn
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Kyungyeon Hwang
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Seung Jae Lee
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Guisuk Park
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Yejong Park
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Woohyung Lee
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Ki Byung Song
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Jae Hoon Lee
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Dae Wook Hwang
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
| | - Song Cheol Kim
- Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center
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15
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Kimura Y, Imamura M, Kuroda Y, Nagayama M, Itoh T, Oota S, Murakami T, Yamaguchi H, Nobuoka T, Kawaharada N, Takemasa I. Clinical usefulness of saphenous vein graft in major arterial reconstruction during extended pancreatectomy. Langenbecks Arch Surg 2020; 405:1051-1059. [DOI: 10.1007/s00423-020-01947-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/22/2020] [Indexed: 12/11/2022]
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16
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Kim HC, Miyayama S, Chung JW. Selective Chemoembolization of Caudate Lobe Hepatocellular Carcinoma: Anatomy and Procedural Techniques. Radiographics 2020; 39:289-302. [PMID: 30620696 DOI: 10.1148/rg.2019180110] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Transarterial chemoembolization is the most common treatment for unresectable hepatocellular carcinomas (HCCs). However, when an HCC is located in the caudate lobe, many interventional radiologists are reluctant to perform chemoembolization and percutaneous ablation owing to the tumor's complex vascular supply and deep location. With the advent of C-arm CT, rendering the three-dimensional display of the hepatic artery and detecting the tumor-feeding vessels are possible and can help guide interventional radiologists to the tumor. The common origins of the caudate artery include the right hepatic artery, left hepatic artery, right anterior hepatic artery, and right posterior hepatic artery. The origins of the tumor-feeding arteries of a caudate lobe HCC can vary depending on the tumor's subsegmental location. Caudate lobe HCCs are commonly fed by multiple caudate arteries that are connected. In addition, extrahepatic collateral arteries frequently supply recurrent tumors in the caudate lobe. The caudate artery can supply portal vein thrombi or biliary tumor thrombi in patients with HCC. Several techniques such as preshaping the microcatheter or using the shepherd's hook technique are needed to catheterize the caudate artery in complex cases. Although uncommon, bile duct stricture is a serious complication following selective chemoembolization through the caudate artery. Identification and catheterization of the caudate artery have become possible in most patients by using C-arm CT and a fine microcatheter system, respectively. The authors review the anatomy of the caudate artery with C-arm CT and describe basic technical considerations in selective chemoembolization for caudate lobe HCCs. Unusual circumstances that require catheterization and techniques used for catheterizing the caudate artery are also described. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Hyo-Cheol Kim
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Korea (H.C.K., J.W.C.); and Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital, Fukui, Japan (S.M.)
| | - Shiro Miyayama
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Korea (H.C.K., J.W.C.); and Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital, Fukui, Japan (S.M.)
| | - Jin Wook Chung
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Korea (H.C.K., J.W.C.); and Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital, Fukui, Japan (S.M.)
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17
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Ezponda A, Rodríguez-Fraile M, Morales M, Vivas I, De La Torre M, Sangro B, Bilbao JI. Hepatic Flow Redistribution is Feasible in Patients with Hepatic Malignancies Undergoing Same-Day Work-Up Angiography and Yttrium-90 Microsphere Radioembolization. Cardiovasc Intervent Radiol 2019; 43:987-995. [PMID: 31848672 DOI: 10.1007/s00270-019-02371-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 10/31/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To assess the feasibility of performing same-day vascular flow redistribution and Yttrium-90 radioembolization (90Y-RE) for hepatic malignancies. MATERIALS AND METHODS From November 2015 to February 2019, patients undergoing same-day hepatic flow redistribution during work-up angiography, 99mTechnetium-labeled macroaggregated albumin (99mTc-MAA) SPECT/CT and 90Y microsphere-RE, were recruited. Within 18 h following the delivery of 90Y resin microspheres, an 90Y-PET/CT study was performed. According to patients' vascular anatomy, flow redistribution was performed by microcoil embolization of extrahepatic branches (group A), intrahepatic non-tumoral vessels (group B) and intrahepatic tumoral arteries (group C). The accumulation of 99mTc-MAA particles and microspheres in the redistributed areas was qualitatively evaluated using a 5-point visual scale (grade 1 = < 25% accumulation; grade 5 = 100% accumulation). Differences in the distribution of microspheres among groups were assessed with Mann-Whitney U test. RESULTS Twenty-two patients were treated for primary (n = 17) and secondary (n = 5) hepatic malignancies. The MAA-SPECT/CT showed uptake in all the redistributed areas. Regarding the accumulation of microspheres within the redistributed segments in all the groups, perfusion patterns were classified as 2 in 1 case, 4 in 6 cases and 5 in 15 cases. No statistically significant differences were observed between groups A and B-C (U value = 34, p = 0.32) and between groups B and C (U value = 26, p = 0.7). Mean predicted absorbed doses by the tumoral and normal hepatic tissues were 163.5 ± 131.2 Gy and 60.4 ± 69.3 Gy, respectively. Mean total procedure time (from work-up angiography to 90Y delivery) was 401 ± 0.055 min. CONCLUSION Performing same-day redistribution of the arterial hepatic flow to the target and 90Y-microsphere delivery is feasible in the treatment of liver tumors. Clinical Trials Registry NCT03380130.
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Affiliation(s)
- A Ezponda
- Department of Radiology, Clínica Universitaria de Navarra, Universidad de Navarra, Avenida de Pio XII n°36, 31008, Pamplona, Spain.
| | - M Rodríguez-Fraile
- Department of Nuclear Medicine, Clínica Universitaria de Navarra, Universidad de Navarra, Avenida de Pio XII n°36, 31008, Pamplona, Spain
| | - M Morales
- Department of Nuclear Medicine, Clínica Universitaria de Navarra, Universidad de Navarra, Avenida de Pio XII n°36, 31008, Pamplona, Spain
| | - I Vivas
- Department of Radiology, Clínica Universitaria de Navarra, Universidad de Navarra, Avenida de Pio XII n°36, 31008, Pamplona, Spain
| | - M De La Torre
- Department of Internal Medicine-Hepatology, Clínica Universidad de Navarra, Universidad de Navarra, Avenida de Pio XII n°36, 31008, Pamplona, Spain.,Clínica Universidad de Navarra, Calle Marquesado de Sta Marta n°1, 28027, Madrid, Spain
| | - B Sangro
- Department of Internal Medicine-Hepatology, Clínica Universidad de Navarra, Universidad de Navarra, Avenida de Pio XII n°36, 31008, Pamplona, Spain.,Clínica Universidad de Navarra, Calle Marquesado de Sta Marta n°1, 28027, Madrid, Spain
| | - J I Bilbao
- Department of Radiology, Clínica Universitaria de Navarra, Universidad de Navarra, Avenida de Pio XII n°36, 31008, Pamplona, Spain
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18
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Kikuchi Y, Matuyama R, Hiroshima Y, Murakami T, Bouvet M, Morioka D, Hoffman RM, Endo I. Surgical and histological boundary of the hepatic hilar plate system: basic study relevant to surgery for hilar cholangiocarcinoma regarding the "true" proximal ductal margin. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:159-168. [PMID: 30825363 DOI: 10.1002/jhbp.617] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND We sought to expand the clinico-anatomical limit of the proximal ductal margin (Limit-PDM) for resectability of hilar cholangiocarcinoma (HCCA). METHODS The practical boundary of the hilar plate (PBHP) was defined as the location where the bile duct (BD) could not be isolated by dissection. The distance between PBHP and two well-known clinical landmarks of Limit-PDM, the right edge of the bifurcation of the anterior and posterior branch of the right portal vein (Posterior-Landmark) and the left edge of the umbilical portion of the portal vein (Left-Landmark), and histological features around the PBHP were assessed using 55 adult cadaver livers. RESULTS BD was almost always isolatable beyond the traditional clinical landmarks. The median distance was 6.9 mm (interquartile range [IQR] 6.0-8.3 mm) between the PBHP and the Posterior-Landmark, and 8.9 mm (IQR 6.7-10.2 mm) between the PBHP and the Left-Landmark. Histologically, the sheath surrounding the portal triad was loose, thick with few elastic fibers and small arteries near the hepatic hilum. Near the PBHP, the sheath was dense, thin, and abundant with elastic fibers and small arteries. CONCLUSIONS Limit-PDM is more peripheral than the traditional clinical landmark-based margin and histological transition near the PBHP was revealed.
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Affiliation(s)
- Yutaro Kikuchi
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Ryusei Matuyama
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Yukihiko Hiroshima
- Department of Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takashi Murakami
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Michael Bouvet
- Department of Surgery, University of California, San Diego, CA, USA
| | - Daisuke Morioka
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Robert M Hoffman
- Department of Surgery, University of California, San Diego, CA, USA
- AntiCancer, Inc., San Diego, CA, USA
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
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19
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Liao FM, Chang MH, Ho MC, Chen HL, Ni YH, Hsu HY, Wu JF. Resistance index of hepatic artery can predict anastomotic biliary complications after liver transplantation in children. J Formos Med Assoc 2019; 118:209-214. [DOI: 10.1016/j.jfma.2018.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/23/2018] [Accepted: 03/27/2018] [Indexed: 02/07/2023] Open
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20
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Aramburu J, Antón R, Rivas A, Ramos JC, Larraona GS, Sangro B, Bilbao JI. Numerical zero-dimensional hepatic artery hemodynamics model for balloon-occluded transarterial chemoembolization. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2018; 34:e2983. [PMID: 29575739 DOI: 10.1002/cnm.2983] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/28/2018] [Accepted: 03/04/2018] [Indexed: 06/08/2023]
Abstract
Balloon-occluded transarterial chemoembolization (B-TACE) is a valuable treatment option for patients with inoperable malignant tumors in the liver. Balloon-occluded transarterial chemoembolization consists of the transcatheter infusion of an anticancer drug mixture and embolic agents. Contrary to conventional TACE, B-TACE is performed via an artery-occluding microballoon catheter, which makes the blood flow to redistribute due to the intra- and extrahepatic arterial collateral circulation. Several recent studies have stressed the importance of the redistribution of blood flow in enhancing the treatment outcome. In the present study, the geometries of a representative hepatic artery and the communicating arcades (CAs) are modeled. An in silico zero-dimensional hemodynamic model is created by characterizing the geometry and the boundary conditions and then is validated in vitro. The role of CAs is assessed by combining 2 cancer scenarios and 2 catheter locations. The importance of the diameter of the CAs is also studied. Results show that occluding a main artery leads to collateral circulation and CAs start to play a role in blood-flow redistribution. In summary, numerical zero-dimensional simulations permit a fast and reliable approach for exploring the blood-flow redistribution caused by the occlusion of a main artery, and this approach could be used during B-TACE planning.
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Affiliation(s)
- Jorge Aramburu
- TECNUN Escuela de Ingenieros, Universidad de Navarra, P° Manuel Lardizabal 13, 20018, Donostia-San Sebastián, Spain
| | - Raúl Antón
- TECNUN Escuela de Ingenieros, Universidad de Navarra, P° Manuel Lardizabal 13, 20018, Donostia-San Sebastián, Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Av. Pío XII 36, 31008, Pamplona, Spain
| | - Alejandro Rivas
- TECNUN Escuela de Ingenieros, Universidad de Navarra, P° Manuel Lardizabal 13, 20018, Donostia-San Sebastián, Spain
| | - Juan Carlos Ramos
- TECNUN Escuela de Ingenieros, Universidad de Navarra, P° Manuel Lardizabal 13, 20018, Donostia-San Sebastián, Spain
| | - Gorka S Larraona
- TECNUN Escuela de Ingenieros, Universidad de Navarra, P° Manuel Lardizabal 13, 20018, Donostia-San Sebastián, Spain
| | - Bruno Sangro
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Av. Pío XII 36, 31008, Pamplona, Spain
- Clínica Universidad de Navarra, Av. Pío XII 36, 31008, Pamplona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Av. Pío XII 36, 31008, Pamplona, Spain
| | - José Ignacio Bilbao
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Av. Pío XII 36, 31008, Pamplona, Spain
- Clínica Universidad de Navarra, Av. Pío XII 36, 31008, Pamplona, Spain
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Asano T, Nakamura T, Noji T, Okamura K, Tsuchikawa T, Nakanishi Y, Tanaka K, Murakami S, Ebihara Y, Kurashima Y, Shichinohe T, Hirano S. Outcome of concomitant resection of the replaced right hepatic artery in pancreaticoduodenectomy without reconstruction. Langenbecks Arch Surg 2018; 403:195-202. [PMID: 29362881 DOI: 10.1007/s00423-018-1650-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/04/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE It has been reported that preoperative embolization or intraoperative reconstruction of the replaced right hepatic artery (rRHA) in order to secure the arterial blood flow to the liver and biliary tract are useful for patients who have undergone pancreaticoduodenectomy (PD) with concomitant rRHA resection. In this study, the feasibility of concomitant resection of rRHA in PD without preoperative embolization or intraoperative reconstruction were retrospectively evaluated with a particular focus on postoperative complications. METHODS We retrospectively analyzed 323 consecutive patients who underwent PD. RESULTS In 51 patients (15.8%), an rRHA was detected. Nine of 51 patients underwent combined rRHA resection during PD. Eight patients showed tumor abutment, and one patient had accidental intraoperative damage of the rRHA. Although there were no cases of bilioenteric anastomotic failure, a hepatic abscess occurred in one patient. This patient was treated with percutaneous transhepatic abscess drainage and was cured immediately without suffering sepsis. Postoperative complications of Clavien-Dindo classification ≥ IIIa were found in three patients, and R0 resection was achieved in six. Surgical outcomes showed no significant differences between the rRHA-resected and non-resected groups. Moreover, there were no significant differences in laboratory data related to liver functions between the rRHA-resected and non-resected groups before surgery and on postoperative days 1, 3, 5, and 7. CONCLUSIONS Simple resection of the rRHA following an unintended or accidental injury during PD is not associated with severe morbidity and should be considered as an alternative to a technically difficult reconstruction.
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Affiliation(s)
- Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan.
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, West-7, North-15, Kita-ku, Sapporo, 060-8638, Japan
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Angiographic Anatomy and Relevance of 3 and 9 O’clock Arteries During Radioembolization. Cardiovasc Intervent Radiol 2018; 41:890-897. [DOI: 10.1007/s00270-017-1873-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 12/29/2017] [Indexed: 01/12/2023]
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23
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Azzam AZ, Tanaka K. Biliary complications after living donor liver transplantation: A retrospective analysis of the Kyoto experience 1999-2004. Indian J Gastroenterol 2017; 36:296-304. [PMID: 28744748 DOI: 10.1007/s12664-017-0771-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 07/02/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM In living donor liver transplantation (LDLT), biliary complications continue to be the most frequent cause of morbidity and may contribute to mortality of recipients although there are advances in surgical techniques. This study will evaluate retrospectively the short-term and long-term management of biliary complications. METHODS During the period from May 1999, to May 2004, 505 patients underwent 518 LDLT in the Department of Liver Transplantation and Immunology, Kyoto University Hospital, Japan. The data was collected and analyzed retrospectively. RESULTS The recipients were 261 males (50.4%) and 257 females (49.6%). Biliary complications were reported in 202/518 patients (39.0%), included; biliary leakage in 79/518 (15.4%) patients, leakage followed by biloma in 13/518 (2.5%) patients, leakage followed by stricture in 9/518 (1.8%) patients, and biliary strictures in 101/518 (19.3%) patients. Proper management of the biliary complications resulted in a significant (p value 0.002) success rate of 96.5% compared to the failure rate which was 3.5%. CONCLUSION Careful preoperative evaluation and the proper intraoperative techniques in biliary reconstruction decrease biliary complications. Early diagnosis and proper management of biliary complications can decrease their effect on both the patient and the graft survival over the long period of follow up.
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Affiliation(s)
- Ayman Zaki Azzam
- General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Koichi Tanaka
- Kobe International Frontier, Medical Center Medical Corporation, Kobe, Japan
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Yamamoto M, Zaima M, Yamamoto H, Harada H, Kawamura J, Yamada M, Yazawa T, Kawasoe J. Liver necrosis shortly after pancreaticoduodenectomy with resection of the replaced left hepatic artery. World J Surg Oncol 2017; 15:77. [PMID: 28399882 PMCID: PMC5387288 DOI: 10.1186/s12957-017-1151-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/02/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Surgeons, in general, underestimate the replaced left hepatic artery (rLHA) that arises from the left gastric artery (LGA), compared with the replaced right hepatic artery (rRHA), especially in standard gastric cancer surgery. During pancreaticoduodenectomy (PD), preservation of the rRHA arising from the superior mesenteric artery (SMA) is widely accepted to prevent critical postoperative complications, such as liver necrosis, bile duct ischemia, and biliary anastomotic leakage. In contrast, details of complication onset following rLHA resection remain unknown. We report two cases of postoperative liver necrosis shortly after rLHA resection during PD for advanced gastric cancer. CASE PRESENTATION Both cases had advanced gastric cancer with infiltration of the pancreatic head. In case 1, the rLHA comprised segment 2/3 artery (A2 + A3), which arose from the LGA. The rRHA originated from the SMA, and the segment 4 artery (A4) was a branch of the rRHA. We conducted PD with combined en bloc resection of both the rLHA and rRHA, and anastomosis between the distal and proximal stumps of the rRHA and LGA, respectively. The divided A2 + A3 was not reconstructed. In case 2, the rLHA comprised segment 2 artery (A2) only, which arose from the LGA. The segment 3/4 artery and the RHAs originated from the proper hepatic artery. We undertook PD with combined en bloc resection of A2 without vascular reconstruction. In both patients, serious necrosis of the lateral segment of the liver occurred within 6 days after PD. Case 1 recovered with conservative management, whereas case 2 required lateral segmentectomy of the liver. Pathologically, the necrotic area in case 2 was apparently circumscribed and confined to segment 2 of the liver, potentially implicating rLHA resection during PD as causing hepatic necrosis. CONCLUSIONS During PD, rLHA resection can cause serious liver necrosis. Therefore, this artery should be preserved as far as oncologically acceptable. In cases that require rLHA resection during PD due to tumor conditions, surgeons should carefully monitor postoperative course while keeping in mind the possible necessity of urgent hepatectomy.
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Affiliation(s)
- Michihiro Yamamoto
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan.
| | - Masazumi Zaima
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Hidekazu Yamamoto
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Hideki Harada
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Junichiro Kawamura
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Masahiro Yamada
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Tekefumi Yazawa
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Junya Kawasoe
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
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Ye S, Dong JH, Duan WD, Ji WB, Liang YR. The Preliminary Study on Procurement Biliary Convergence from Donors with Complicated Bile Duct Variant in Emergency Right Lobe Living Donor Liver Transplantation. J Clin Exp Hepatol 2017; 7:33-41. [PMID: 28348469 PMCID: PMC5357717 DOI: 10.1016/j.jceh.2016.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 09/28/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The incidence of biliary complications after living donor adult liver transplantation (LDALT) is still high due to the bile duct variation and necessity reconstruction of multiple small bile ducts. The current surgical management of the biliary variants is unsatisfactory. We evaluated the role of a new surgical approach in a complicated hilar bile duct variant (Nakamura type IV and Nakamura type II) under emergent right lobe LDALT for high model for end-stage liver disease score patients. METHODS The common hepatic duct (CHD) and the left hepatic duct (LHD) of the donor were transected in a right-graft including short common trunks with right posterior and anterior bile ducts, whereas the LHD of the donor was anastomosed to the CHD and the common trunks of a right-graft bile duct and the recipient CHD was end-to-end anastomosed. RESULTS Ten of 13 grafts (Nakamura types II, III, and IV) had two or more biliary orifices after right graft lobectomy; seven patients had biliary complications (53.8%). Later, the surgical innovation was carried out in five donors with variant bile duct (four Nakamura type IV and one type II), and, consequently, no biliary or other complications were observed in donors and recipients during 47-53 months of follow-up; significant differences (P < 0.05) were found when two stages were compared. CONCLUSION Our initial experience suggests that, in the urgent condition of LDALT when an alternative live donor was unavailable, a surgical innovation of cutting part of the CHD trunks including variant right hepatic ducts in a complicated donor bile duct variant may facilitate biliary reconstruction and reduce long-term biliary complications.
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Key Words
- CHD, common hepatic duct
- CUSA, cavitron ultrasonic surgical aspirator
- CVP, central venous pressure
- HTK, histidine-tryptophan-ketoglutarate
- LDALT, living donor adult liver transplantation
- LDLT
- LHD, left hepatic duct
- MELD, model for end-stage liver disease
- MHA, middle hepatic artery
- MHV, middle hepatic vein
- MRCP, magnetic resonance cholangiopancreatography
- PHA, proper hepatic artery
- RHA, right hepatic artery
- RHD, right hepatic duct
- RHV, right hepatic vein
- RPV, right portal vein
- bile duct variant
- biliary complications
- surgical innovation
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Affiliation(s)
- Sheng Ye
- Department of Hepatobiliary Surgery, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, 168 Litang Road, Dongxiaokou Town, Changping District, Beijing 102218, China,Address for correspondence: Sheng Ye, Department of Hepatobiliary Surgery, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, 168 Litang Road, Dongxiaokou Town, Changping District, Beijing 102218, China. Fax: +86 10 56118500.Department of Hepatobiliary Surgery, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University168 Litang Road, Dongxiaokou Town, Changping DistrictBeijing102218China
| | - Jia-Hong Dong
- Department of Hepatobiliary Surgery, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, 168 Litang Road, Dongxiaokou Town, Changping District, Beijing 102218, China
| | - Wei-Dong Duan
- Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, 28 Fuxin Road, Beijing 100853, China
| | - Wen-Bing Ji
- Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, 28 Fuxin Road, Beijing 100853, China
| | - Yu-Rong Liang
- Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, 28 Fuxin Road, Beijing 100853, China
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26
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Low Measured Hepatic Artery Flow Increases Rate of Biliary Strictures in Deceased Donor Liver Transplantation. Transplantation 2017; 101:332-340. [DOI: 10.1097/tp.0000000000001564] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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27
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Koh PS, Chan SC. Adult-to-adult living donor liver transplantation: Operative techniques to optimize the recipient's outcome. J Nat Sci Biol Med 2017; 8:4-10. [PMID: 28250667 PMCID: PMC5320821 DOI: 10.4103/0976-9668.198356] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Adult-to-adult living donor liver transplantation (LDLT) is widely accepted today with good outcomes and safety reported worldwide for both donor and recipient. Nonetheless, it remained a highly demanding technical and complex surgery if undertaken. The last two decades have seen an increased in adult-to-adult LDLT following our first report of right lobe LDLT in overcoming graft size limitation in adults. In this article, we discussed the operative techniques and challenges of adult right lobe LDLT incorporating the middle hepatic vein, which is practiced in our center for the recipient operation. The various issues and challenges faced by the transplant surgeon in ensuring good recipient outcome are explored and discussed here as well. Hence, it is important to understand that a successful recipient operation is dependent of multifactorial events starting at the preoperative stage of planning, understanding the intraoperative technical challenges and the physiology of flow modulation that goes hand-in-hand with the operation. Therefore, one needs to arm oneself with all the possible knowledge in overcoming these technical challenges and the ability to be flexible and adaptable during LDLT by tailoring the needs of each patient individually.
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Affiliation(s)
- Peng Soon Koh
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - See Ching Chan
- Department of Surgery, The University of Hong Kong, Hong Kong, SAR, China
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28
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Braun HJ, Ascher NL, Roll GR, Roberts JP. Biliary complications following living donor hepatectomy. Transplant Rev (Orlando) 2016; 30:247-52. [PMID: 27531698 DOI: 10.1016/j.trre.2016.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 04/26/2016] [Accepted: 07/13/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) has become increasingly common in an effort to increase organ availability for the treatment of end-stage liver disease. Donor safety is a primary concern in LDLT. The majority of complications experienced by living donors are infectious or biliary in nature. The purpose of this paper was to review the existing literature on biliary complications in living donors. METHODS Studies were eligible for inclusion if they were published in English between 2006-present, focused on adult-to-adult LDLT, and were available via PubMed/MEDLINE. RESULTS A total of 33 studies reporting outcomes from 12,653 donors (right lobe: 8231, left lobe: 4422) were included. Of 33 studies, 12 reported outcomes from right lobe donors, 1 from left lobe donors, 14 compared left and right, and 6 focused specifically on biliary complications. A total of 830 biliary complications (6.6%) were reported, with 75 donors requiring re-operation for biliary complications and 1 donor death attributed to biliary complications. CONCLUSION Although bile leaks and strictures are still relatively common following living donor hepatectomy, the majority of complications are minor and resolve with conservative measures. Approximately 6% of living donors will experience a biliary complication and, of these 6%, approximately 9% (total of 0.6% of donors) will require operative management of the biliary complication.
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Affiliation(s)
- Hillary J Braun
- School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Nancy L Ascher
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Garrett R Roll
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - John P Roberts
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Analysis of Factors Associated With Biliary Complications in Children After Liver Transplantation. Transplantation 2016; 100:1944-54. [DOI: 10.1097/tp.0000000000001298] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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30
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Noji T, Tsuchikawa T, Okamura K, Tanaka K, Nakanishi Y, Asano T, Nakamura T, Shichinohe T, Hirano S. Concomitant hepatic artery resection for advanced perihilar cholangiocarcinoma: a case-control study with propensity score matching. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:442-448. [DOI: 10.1002/jhbp.363] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Takehiro Noji
- Department of Gastroenterological Surgery II; Hokkaido University Graduate School of Medicine; Kita 15 Nishi 7, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II; Hokkaido University Graduate School of Medicine; Kita 15 Nishi 7, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II; Hokkaido University Graduate School of Medicine; Kita 15 Nishi 7, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II; Hokkaido University Graduate School of Medicine; Kita 15 Nishi 7, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II; Hokkaido University Graduate School of Medicine; Kita 15 Nishi 7, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II; Hokkaido University Graduate School of Medicine; Kita 15 Nishi 7, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II; Hokkaido University Graduate School of Medicine; Kita 15 Nishi 7, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II; Hokkaido University Graduate School of Medicine; Kita 15 Nishi 7, Kita-ku Sapporo Hokkaido 060-8638 Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II; Hokkaido University Graduate School of Medicine; Kita 15 Nishi 7, Kita-ku Sapporo Hokkaido 060-8638 Japan
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Vij V, Makki K, Chorasiya VK, Sood G, Singhal A, Dargan P. Targeting the Achilles' heel of adult living donor liver transplant: Corner-sparing sutures with mucosal eversion technique of biliary anastomosis. Liver Transpl 2016; 22:14-23. [PMID: 26390361 DOI: 10.1002/lt.24343] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 08/19/2015] [Accepted: 09/10/2015] [Indexed: 12/14/2022]
Abstract
Biliary complications are regarded as the Achilles' heel of liver transplantation, especially for living donor liver transplantation (LDLT) due to smaller, multiple ducts and difficult ductal anatomy. Overall biliary complications reported in most series are between 10% and 30%. This study describes our modified technique of biliary anastomosis and its effects on incidence of biliary complications. This was a single-center retrospective study of 148 adult LDLT recipients between December 2011 and June 2014. Group 1 (n = 40) consisted of the first 40 patients for whom the standard technique of biliary anastomosis (minimal hilar dissection during donor duct division, high hilar division of the recipient bile duct, and preservation of the recipient duct periductal tissue) was used. Group 2 (n = 108) consisted of 108 patients for whom biliary anastomosis was done with the addition of corner-sparing sutures and mucosal eversion of the recipient duct to the standard technique. Primary outcome measures included biliary complications (biliary leaks and strictures). Biliary complications occurred in 7/40 patients in group 1 (17.5%) and in 4/108 patients in group 2 (3.7%). The technical factors mentioned above are aimed at preserving the blood supply of the donor and recipient ducts and hold the key for minimizing biliary complications in adult-to-adult LDLT.
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Affiliation(s)
- Vivek Vij
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Kausar Makki
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Vishal Kumar Chorasiya
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Gaurav Sood
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Ashish Singhal
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
| | - Puneet Dargan
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Fortis Hospital, Noida, India
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Preoperative Coil Embolization in Patients With a Replaced Hepatic Artery Scheduled for Pancreatectomy With Splanchnic Artery Resection Helps to Prevent Ischemic Organ Injury. J Comput Assist Tomogr 2016; 40:172-6. [DOI: 10.1097/rct.0000000000000325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Matsumoto T, Endo J, Hashida K, Mizukami H, Nagata J, Ichikawa H, Kojima S, Takashimizu S, Yamagami T, Watanabe N, Hasebe T. Balloon-occluded arterial stump pressure before balloon-occluded transarterial chemoembolization. MINIM INVASIV THER 2015; 25:22-8. [PMID: 26406612 DOI: 10.3109/13645706.2015.1086381] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate balloon-occluded arterial stump pressure (BOASP), which is responsible for effective balloon-occluded transarterial chemoembolization (B-TACE), at each hepatic arterial level before B-TACE using a 1.8-French tip microballoon catheter for unresectable hepatocellular carcinoma (HCC). MATERIAL AND METHODS The BOASP at various embolization portions was retrospectively investigated. "Selective" and "non-targeted" BOASP was defined as the BOASP at the subsegmental or segmental artery and the lobar artery, respectively. RESULTS The measurement of the BOASP was carried out in 87 arteries in 47 patients. BOASP > 64 mmHg was revealed in the caudate lobe artery (A1) and the left medial segmental (A4), right anterior superior segmental (A8), anterior segmental, right and left hepatic arteries. Significant difference was noted in the incidence of BOASP above 64 mmHg between "non-targeted" and "selective" BOASP (p = 0.01). "Non-targeted" BOASP was significantly greater than "selective" BOASP (p = 0.0147). In addition, the BOASP in A1, 4, 8 and the anterior segmental arteries were significantly greater than in the other subsegmental and segmental arteries (p = 0.0007). CONCLUSION "Non-targeted" B-TACE should be avoided to perform effective B-TACE and "selective" B-TACE at A1, 4, 8 and the anterior segmental arteries may become less effective than at the other segmental or subsegmental arteries.
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Affiliation(s)
- Tomohiro Matsumoto
- a Department of Radiology , Tokai University Hachioji Hospital, Tokai University School of Medicine , Tokyo , Japan
| | - Jun Endo
- a Department of Radiology , Tokai University Hachioji Hospital, Tokai University School of Medicine , Tokyo , Japan
| | - Kazunobu Hashida
- a Department of Radiology , Tokai University Hachioji Hospital, Tokai University School of Medicine , Tokyo , Japan
| | - Hajime Mizukami
- b Department of Gastroenterology , Tokai University Hachioji Hospital, Tokai University School of Medicine , Tokyo , Japan , and
| | - Junko Nagata
- b Department of Gastroenterology , Tokai University Hachioji Hospital, Tokai University School of Medicine , Tokyo , Japan , and
| | - Hitoshi Ichikawa
- b Department of Gastroenterology , Tokai University Hachioji Hospital, Tokai University School of Medicine , Tokyo , Japan , and
| | - Seiichiro Kojima
- b Department of Gastroenterology , Tokai University Hachioji Hospital, Tokai University School of Medicine , Tokyo , Japan , and
| | - Shinji Takashimizu
- b Department of Gastroenterology , Tokai University Hachioji Hospital, Tokai University School of Medicine , Tokyo , Japan , and
| | - Takuji Yamagami
- c Department of Radiology , Kochi University , Kohasu, Oko-cho, Nankoku , Kochi , Japan
| | - Norihito Watanabe
- b Department of Gastroenterology , Tokai University Hachioji Hospital, Tokai University School of Medicine , Tokyo , Japan , and
| | - Terumitsu Hasebe
- a Department of Radiology , Tokai University Hachioji Hospital, Tokai University School of Medicine , Tokyo , Japan
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Extravascular complications following abdominal organ transplantation. Clin Radiol 2015; 70:898-908. [DOI: 10.1016/j.crad.2015.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 03/03/2015] [Accepted: 04/09/2015] [Indexed: 12/15/2022]
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Simoes P, Kesar V, Ahmad J. Spectrum of biliary complications following live donor liver transplantation. World J Hepatol 2015; 7:1856-1865. [PMID: 26207167 PMCID: PMC4506943 DOI: 10.4254/wjh.v7.i14.1856] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/22/2015] [Accepted: 07/08/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is the optimal treatment for many patients with advanced liver disease, including decompensated cirrhosis, hepatocellular carcinoma and acute liver failure. Organ shortage is the main determinant of death on the waiting list and hence living donor liver transplantation (LDLT) assumes importance. Biliary complications are the most common post operative morbidity after LDLT and occur due to anatomical and technical reasons. They include biliary leaks, strictures and cast formation and occur in the recipient as well as the donor. The types of biliary complications after LDLT along with their etiology, presenting features, diagnosis and endoscopic and surgical management are discussed.
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Weeder PD, van Rijn R, Porte RJ. Machine perfusion in liver transplantation as a tool to prevent non-anastomotic biliary strictures: Rationale, current evidence and future directions. J Hepatol 2015; 63:265-75. [PMID: 25770660 DOI: 10.1016/j.jhep.2015.03.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 02/25/2015] [Accepted: 03/02/2015] [Indexed: 02/08/2023]
Abstract
The high incidence of non-anastomotic biliary strictures (NAS) after transplantation of livers from extended criteria donors is currently a major barrier to widespread use of these organs. This review provides an update on the most recent advances in the understanding of the etiology of NAS. These new insights give reason to believe that machine perfusion can reduce the incidence of NAS after transplantation by providing more protective effects on the biliary tree during preservation of the donor liver. An overview is presented regarding the different endpoints that have been used for assessment of biliary injury and function before and after transplantation, emphasizing on methods used during machine perfusion. The wide spectrum of different approaches to machine perfusion is discussed, including the many different combinations of techniques, temperatures and perfusates at varying time points. In addition, the current understanding of the effect of machine perfusion in relation to biliary injury is reviewed. Finally, we explore directions for future research such as the application of (pharmacological) strategies during machine perfusion to further improve preservation. We stress the great potential of machine perfusion to possibly expand the donor pool by reducing the incidence of NAS in extended criteria organs.
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Affiliation(s)
- Pepijn D Weeder
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rianne van Rijn
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Resection and reconstruction of the hepatic artery for advanced perihilar cholangiocarcinoma: result of arterioportal shunting. J Gastrointest Surg 2015; 19:675-81. [PMID: 25650165 DOI: 10.1007/s11605-015-2754-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Accepted: 01/19/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND The clinical impact of concomitant arterial resection and reconstruction for perihilar cholangiocarcinoma remains unclear. Microvascular anastomosis is typically used for arterial reconstruction, but we have proposed arterioportal shunting (APS) as an alternative procedure. The aims of this retrospective study were to evaluate concomitant arterial resection and reconstruction for perihilar cholangiocarcinoma patients, to evaluate the safety and survival impact of APS, and to evaluate whether APS offers a good alternative to microvascular reconstruction. PATIENTS AND METHODS Thirty-nine patients with perihilar cholangiocarcinoma who required arterial reconstructions were retrospectively evaluated. RESULTS No significant difference was seen in overall incidence of postoperative complications between groups, but the incidence of liver abscess formation was significantly higher in the APS group. The cumulative 5-year survival rate was 15% in patients undergoing concomitant arterial resection and reconstruction for perihilar cholangiocarcinoma. No significant differences in survival were identified between the microvascular (MV) and APS groups. Cumulative 5-year survival rates were 18% in the MV group and 11% in the APS group. CONCLUSION Concomitant arterial resection and reconstruction are feasible for patients with perihilar cholangiocarcinoma. Microvascular reconstruction should be used as the first-line strategy for these patients, with APS indicated only when the artery is unable to be microscopically anastomosed.
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Dai J, Wu XF, Yang C, Li HJ, Chen YL, Liu GZ, Song YZ, Wu HH, Ding JL, Li N. Study of relationship between the blood supply of the extrahepatic bile duct and duct supply branches from gastroduodenal artery on imaging and anatomy. Chin Med J (Engl) 2015; 128:322-6. [PMID: 25635427 PMCID: PMC4837862 DOI: 10.4103/0366-6999.150097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Liver transplantation has become the treatment of choice for patients with end-stage acute or chronic hepatic disease. Bile duct complications are common events after liver transplantation. The aim of this study was to evaluate the blood supply of the human bile duct and identify the underlying mechanisms of bile duct complications after liver transplantation. Methods: The duct supply branches from gastroduodenal artery and blood supply of extrahepatic bile duct system were re-evaluated through selective hepatic angiography from 600 patients. In addition, 33 cadavers were injected with latex casting material into the common hepatic artery, then the extrahepatic bile duct and the branches from the common hepatic artery were carefully dissected to visualize the gastroduodenal artery and its branching to the extrahepatic bile duct. Results: The bile duct artery arose from the branch of the gastroduodenal artery in 8.1% (49/600). Of these 49 individuals, the bile duct artery was supplied by the gastroduodenal artery (61.22%, 30/49), the proper hepatic artery (14.29%, 7/49), or both the gastroduodenal artery and the proper hepatic artery (24.49%, 12/49). In our study of 33 cadavers, the percentage that the bile duct artery arose from the gastroduodenal artery was 27.27%. The blood supply to the bile extrahepatic bile ducts was divided into different segments and formed longitudinal and arterial network anastomosed on the walls of the duct. Conclusions: There is a close relationship between the duct supply branches from gastroduodenal artery and the blood supplying patterns of the extrahepatic bile duct system. In liver transplant surgery, the initial part of the gastroduodenal artery is preferred to be preserved in the donor liver. It is of great significance to improve the success rate of operation and reduce complications.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ning Li
- Department of Radiology, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
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39
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Bilbao JI. Radioembolization and the Cystic Artery. J Vasc Interv Radiol 2014; 25:1724-6. [DOI: 10.1016/j.jvir.2014.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 07/10/2014] [Accepted: 08/07/2014] [Indexed: 12/20/2022] Open
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40
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Kim JM, Cho W, Kwon CHD, Joh JW, Park JB, Ko JS, Gwak MS, Kim GS, Kim SJ, Lee SK. Bile duct reconstruction by a young surgeon in living donor liver transplantation using right liver graft. Medicine (Baltimore) 2014; 93:e84. [PMID: 25255023 PMCID: PMC4616285 DOI: 10.1097/md.0000000000000084] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Biliary strictures and bile leaks account for the majority of biliary complications after living donor liver transplantation (LDLT). The aim of this study was to examine differences in biliary complications after adult LDLTs were performed by an experienced senior surgeon and an inexperienced junior surgeon. Surgeries included bile duct reconstruction after adult LDLT using a right liver graft, and risk factors for biliary stricture were identified. We retrospectively reviewed the medical records of 136 patients who underwent LDLT in order to identify patients who developed biliary complications. The senior surgeon performed 102 surgeries and the junior surgeon performed 34 surgeries. The proportion of patients with biliary stricture was similar between the senior and the junior surgeons (27.5% vs 26.5%; P = 0.911). However, the incidence of biliary leakage was higher in patients of the junior surgeon than in those of the senior surgeon (23.5% vs 2.9%; P = 0.001). The frequency of percutaneous drainage was also higher for the junior surgeon than the senior surgeon because of the junior surgeon's high leakage rate of the drainage. When the junior surgeon performed bile duct anastomosis, biliary leakage occurred in 7 patients between the 11th and 20th cases. However, biliary leakage occurred in only 1 case thereafter. Bile duct reconstruction performed by beginner surgeons in LDLT using right lobe grafts should be cautiously monitored and observed by a senior surgeon until an inexperienced junior surgeon has performed at least 20 cases, because of the high incidence of biliary leakage related to surgeon's inexperience in bile duct reconstructions in LDLT.
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Affiliation(s)
- Jong Man Kim
- Department of Surgery, Samsung Medical Center (JMK, WC, CHDK, J-WJ, JBP, SJK, SKL); and Department of Anesthesiology and Pain Medicine (JSK, MSG, GSK), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Darius T, Rivera J, Fusaro F, Lai Q, de Magnée C, Bourdeaux C, Janssen M, Clapuyt P, Reding R. Risk factors and surgical management of anastomotic biliary complications after pediatric liver transplantation. Liver Transpl 2014; 20:893-903. [PMID: 24809592 DOI: 10.1002/lt.23910] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 04/25/2014] [Accepted: 05/06/2014] [Indexed: 01/01/2023]
Abstract
Biliary complications (BCs) still remain the Achilles heel of liver transplantation (LT) with an overall incidence of 10% to 35% in pediatric series. We hypothesized that (1) the use of alternative techniques (reduced size, split, and living donor grafts) in pediatric LT may contribute to an increased incidence of BCs, and (2) surgery as a first treatment option for anastomotic BCs could allow a definitive cure for the majority of these patients. Four hundred twenty-nine primary pediatric LT procedures, including 88, 91, 47, and 203 whole, reduced size, split, and living donor grafts, respectively, that were performed between July 1993 and November 2010 were retrospectively reviewed. Demographic and surgical variables were analyzed, and their respective impact on BCs was studied with univariate and multivariate analyses. The modalities of BC management were also reviewed. The 1- and 5-year patient survival rates were 94% and 90%, 89% and 85%, 94% and 89%, and 98% and 94% for whole, reduced size, split, and living donor liver grafts, respectively. The overall incidence of BCs was 23% (n = 98). Sixty were anastomotic complications [47 strictures (78%) and 13 fistulas (22%)]. The graft type was not found to be an independent risk factor for the development of BCs. According to a multivariate analysis, only hepatic artery thrombosis and acute rejection increased the risk of anastomotic BCs (P < 0.001 and P = 0.003, respectively). Anastomotic BCs were managed primarily with surgical repair in 59 of 60 cases with a primary patency rate of 80% (n = 47). These results suggest that (1) most of the BCs were anastomotic complications not influenced by the type of graft, and (2) the surgical management of anastomotic BCs may constitute the first and best therapeutic option.
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Affiliation(s)
- Tom Darius
- Pediatric Surgery and Transplant Unit, Université Catholique de Louvain, Brussels, Belgium
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Girometti R, Cereser L, Bazzocchi M, Zuiani C. Magnetic resonance cholangiography in the assessment and management of biliary complications after OLT. World J Radiol 2014; 6:424-436. [PMID: 25071883 PMCID: PMC4109094 DOI: 10.4329/wjr.v6.i7.424] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/05/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Despite advances in patient and graft management, biliary complications (BC) still represent a challenge both in the early and delayed period after orthotopic liver transplantation (OLT). Because of unspecific clinical presentation, imaging is often mandatory in order to diagnose BC. Among imaging modalities, magnetic resonance cholangiography (MRC) has gained widespread acceptance as a tool to represent the reconstructed biliary tree noninvasively, using both the conventional technique (based on heavily T2-weighted sequences) and contrast-enhanced MRC (based on the acquisition of T1-weighted sequences after the administration of hepatobiliary contrast agents). On this basis, MRC is generally indicated to: (1) avoid unnecessary procedures of direct cholangiography in patients with a negative examination and/or identify alternative complications; and (2) provide a road map for interventional procedures or surgery. As illustrated in the review, MRC is accurate in the diagnosis of different types of biliary complications, including anastomotic strictures, non-anastomotic strictures, leakage and stones.
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43
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Intrahepatic Flow Redistribution in Patients Treated with Radioembolization. Cardiovasc Intervent Radiol 2014; 38:322-8. [DOI: 10.1007/s00270-014-0921-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 04/21/2014] [Indexed: 02/07/2023]
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Ramesh Babu CS, Sharma M. Biliary tract anatomy and its relationship with venous drainage. J Clin Exp Hepatol 2014; 4:S18-26. [PMID: 25755590 PMCID: PMC4244820 DOI: 10.1016/j.jceh.2013.05.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 05/01/2013] [Indexed: 02/08/2023] Open
Abstract
Portal cavernoma develops as a bunch of hepatopetal collaterals in response to portomesenteric venous obstruction and induces morphological changes in the biliary ducts, referred to as portal cavernoma cholangiopathy. This article briefly reviews the available literature on the vascular supply of the biliary tract in the light of biliary changes induced by portal cavernoma. Literature pertaining to venous drainage of the biliary tract is scanty whereas more attention was focused on the arterial supply probably because of its significant surgical implications in liver transplantation and development of ischemic changes and strictures in the bile duct due to vasculobiliary injuries. Since the general pattern of arterial supply and venous drainage of the bile ducts is quite similar, the arterial supply of the biliary tract is also reviewed. Fine branches from the posterior superior pancreaticoduodenal, retroportal, gastroduodenal, hepatic and cystic arteries form two plexuses to supply the bile ducts. The paracholedochal plexus, as right and left marginal arteries, run along the margins of the bile duct and the reticular epicholedochal plexus lie on the surface. The retropancreatic, hilar and intrahepatic parts of biliary tract has copious supply, but the supraduodenal bile duct has the poorest vascularization and hence susceptible to ischemic changes. Two venous plexuses drain the biliary tract. A fine reticular epicholedochal venous plexus on the wall of the bile duct drains into the paracholedochal venous plexus (also called as marginal veins or parabiliary venous system) which in turn is connected to the posterior superior pancreaticoduodenal vein, gastrocolic trunk, right gastric vein, superior mesenteric vein inferiorly and intrahepatic portal vein branches superiorly. These pericholedochal venous plexuses constitute the porto-portal collaterals and dilate in portomesenteric venous obstruction forming the portal cavernoma.
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Key Words
- AIPDV, anterior inferior pancreaticoduodenal vein
- ASPDV, anterior superior pancreaticoduodenal vein
- CA, communicating arcade
- CBD, common bile duct
- CD, cystic duct
- CHA, common hepatic artery
- CHD, common hepatic duct
- FJV, first jejunal vein
- GCT, gastrocolic trunk
- GDA, gastroduodenal artery
- HABr, hepatic arteriolar branches
- IHBD, intrahepatic bile ductules
- LHA, left hepatic artery
- LHD, left hepatic duct
- PBP, peribiliary plexus
- PD, pancreatic duct
- PSPDA, posterior superior pancreaticoduodenal artery
- PSPDV, posterior superior pancreaticoduodenal vein
- PVBr, portal vein branches
- RASD, right anterior sectoral duct
- RGV, right gastric vein
- RHA, right hepatic artery
- RHD, right hepatic duct
- RPSD, right posterior sectoral duct
- SMV, superior mesenteric vein
- SRCV, superior right colic vein
- SV, splenic vein
- epicholedochal plexus
- parabiliary venous system
- paracholedochal plexus
- porto-portal collaterals
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Affiliation(s)
- Chittapuram S. Ramesh Babu
- Muzaffarnagar Medical College, NH-58, Opposite Beghrajpur Industrial Area, Muzaffarnagar, 251203, UP, India,Address for correspondence. Chittapuram S. Ramesh Babu, Associate Professor of Anatomy, Muzaffarnagar Medical College, NH-58, Opposite Beghrajpur Industrial Area, Muzaffarnagar 251203, UP, India. Tel.: +91 9897249202 (mobile).
| | - Malay Sharma
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Meerut, 250001, UP, India
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Seehofer D, Eurich D, Veltzke-Schlieker W, Neuhaus P. Biliary complications after liver transplantation: old problems and new challenges. Am J Transplant 2013; 13:253-65. [PMID: 23331505 DOI: 10.1111/ajt.12034] [Citation(s) in RCA: 192] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/01/2012] [Accepted: 10/23/2012] [Indexed: 01/25/2023]
Abstract
Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable.
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Affiliation(s)
- D Seehofer
- Department of General-, Visceral and Transplantation Surgery, Charité Campus Virchow, Berlin, Germany.
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46
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Abstract
Biliary complications occur more frequently after living donor liver transplantation (LDLT) versus deceased donor liver transplantation, and they remain the most common and intractable problems after LDLT. The anatomical limitations of multiple tiny bile ducts and the differential blood supplies of the graft ducts may be significant factors in the pathophysiological mechanisms of biliary complications in patients undergoing LDLT. A clear understanding of the biliary blood supply, the Glissonian sheath, and the hilar plate has contributed to new techniques for preparing bile ducts for anastomosis, and these techniques have resulted in a dramatic drop in the incidence of biliary complications. Most biliary complications after LDLT can be successfully treated with nonsurgical approaches, although the management of multiple biliary anastomoses and nonanastomotic strictures continues to be a challenge.
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Affiliation(s)
- Shao Fa Wang
- Key Laboratory of Organ Transplantation, Ministry of Education, China and Key Laboratory of Organ Transplantation, Ministry of Public Health, China
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47
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Biliary Dilatation and Strictures After Composite Liver–Small Bowel Transplantation in Children: Defining a Newly Recognized Complication. Transplantation 2011; 92:461-8. [DOI: 10.1097/tp.0b013e318225278e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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48
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[Extrahepatic vessels depending on the hepatic artery. Identification and management]. RADIOLOGIA 2011; 53:18-26. [PMID: 21295805 DOI: 10.1016/j.rx.2010.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 07/31/2010] [Indexed: 01/06/2023]
Abstract
Patients with malignant liver tumors, whether primary tumors or metastases, that are not candidates for surgical treatment can benefit from different endovascular treatments with proven efficacy in local control of the disease. Correct treatment requires a careful angiographic technique and precise knowledge about the vascular anatomy afferent to the lesion. Occasionally, lesions considered relapse are actually areas that were untreated because the afferent pedicle was not adequately detected. On the other hand, some of the complications of endovascular treatments are related with material passing into non-hepatic vessels. Knowing the hepatic vascular anatomy and correctly identifying all the extrahepatic vessels will make it possible to perform safer, more efficacious treatments. In this article, we present different representative examples of extrahepatic vessels that originate in the hepatic artery.
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49
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Extrahepatic vessels depending on the hepatic artery. Identification and management. RADIOLOGIA 2011. [DOI: 10.1016/s2173-5107(11)70002-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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50
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Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford) 2011; 13:1-14. [PMID: 21159098 PMCID: PMC3019536 DOI: 10.1111/j.1477-2574.2010.00225.x] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 07/22/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Biliary injuries are frequently accompanied by vascular injuries, which may worsen the bile duct injury and cause liver ischemia. We performed an analytical review with the aim of defining vasculobiliary injury and setting out the important issues in this area. METHODS A literature search of relevant terms was performed using OvidSP. Bibliographies of papers were also searched to obtain older literature. RESULTS Vasculobiliary injury was defined as: an injury to both a bile duct and a hepatic artery and/or portal vein; the bile duct injury may be caused by operative trauma, be ischaemic in origin or both, and may or may not be accompanied by various degrees of hepatic ischaemia. Right hepatic artery (RHA) vasculobiliary injury (VBI) is the most common variant. Injury to the RHA likely extends the biliary injury to a higher level than the gross observed mechanical injury. VBI results in slow hepatic infarction in about 10% of patients. Repair of the artery is rarely possible and the overall benefit unclear. Injuries involving the portal vein or common or proper hepatic arteries are much less common, but have more serious effects including rapid infarction of the liver. CONCLUSIONS Routine arteriography is recommended in patients with a biliary injury if early repair is contemplated. Consideration should be given to delaying repair of a biliary injury in patients with occlusion of the RHA. Patients with injuries to the portal vein or proper or common hepatic should be emergently referred to tertiary care centers.
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Affiliation(s)
- Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in Saint Louis, St Louis, MO 63110, USA.
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