"Passing loop" technique: a new modification of the piggyback technique tailored to voluminous liver grafts--case report

Graft reduction in adult liver transplantation: indications, techniques, and outcomes

PURPOSE

Graft reduction can be a patient's graft-saving option to avoid large-for-size (LFS) syndrome. This study aimed to summarize the literature on graft reduction in adult liver transplantation and to demonstrate the technique of H67 graft hepatectomy.

METHODS

The technique, shown in a didactical video, entails an ex situ posterior sectionectomy under hypothermic perfusion. The right hepatic vein is identified, and the transection line follows the right hepatic fissure. The Glissonean pedicles are ligated during parenchymal transection.

RESULTS

A narrative review of the literature yielded 7 studies. A total of 15 liver grafts were reduced in adult liver transplantations. Most of the reductions were ex situ (11/15 [73.3%]). Graft reduction entailed an H67 sectionectomy in 10 cases and an H23 sectionectomy in 1 case. In situ reduction included 1 right hepatectomy (H5678), 2 H67 sectionectomies, and 1 H23 left lateral sectionectomy. The duration of the ex situ reduction averaged 56 minutes (median: 40.5 minutes; IQR, 33.0-130.0), and the graft weight-to-recipient weight ratio decreased from 3.57% ± 0.40% to 2.70% ± 0.50% after graft reduction. The average cold ischemia time was 390 minutes (IQR, 230-570). There was no liver retransplantation.

CONCLUSION

Graft reduction in adult liver transplantation may be necessary to avoid LFS syndrome. Ex-situ H67 posterior sectionectomy represents the easiest graft reduction hepatectomy and is able to minimize the occurrence of graft compression while leaving enough functional liver parenchyma.

A Novel Strategy for Preventing Posttransplant Large-For-Size Syndrome in Adult Liver Transplant Recipients: A Pilot Study

There are two causes of graft compression in the large-for-size syndrome (LFSS). One is a shortage of intra-abdominal space for the liver graft, and the other is the size discrepancy between the anteroposterior dimensions of the liver graft and the lower right hemithorax of the recipient. The former could be treated using delayed fascial closure or mesh closure, but the latter may only be treated by reduction of the right liver graft to increase space. Given that split liver transplantation has strict requirements regarding donor and recipient selections, reduced-size liver transplantation, in most cases, may be the only solution. However, surgical strategies for the reduction of the right liver graft for adult liver transplantations are relatively unfamiliar. Herein, we introduce a novel strategy of HuaXi-ex vivo right posterior sectionectomy while preserving the right hepatic vein in the graft to prevent LFSS and propose its initial indications.

Large-for-Size Orthotopic Liver Transplantation: a Systematic Review of Definitions, Outcomes, and Solutions

BACKGROUND

We systematically reviewed the literature on definitions and outcomes of large-for-size (LFS) syndrome in orthotopic liver transplantation (LT).

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The Cochrane Library, PubMed, and Embase were searched (January 1990-January 2019) for studies reporting LFS in LT. Primary outcomes were definitions and mortality of LFS LT.

RESULTS

Eleven studies reporting patients with LFS LT were identified. Four different formulas (graft-to-recipient weight ratio (GRWR), body surface area index (BSAi), donor standardized total liver volume (sTLV)-to-recipient sTLV ratio, and graft weight/right anteroposterior distance (RAP) ratio) with their critical thresholds were found. There were 81 patients (54% women) with a median weight and height of 62.5 kg (range, 40-105 kg) and 165 cm (range, 145-180 cm). The median graft weight was 1772 g (range, 1290-2400 g), and the median GWRW was 2.77% (range, 2.1-4.00%). Graft venous outflow obstruction was described in seven patients (8.6%). At the time of LT, fascial closure was not achieved in 24 patients (29.6%) and the graft size was reduced by a liver resection in three patients (3.7%). Thirteen deaths (16%) were reported in the first 90 postoperative days with two patients undergoing re-transplant.

CONCLUSIONS

LFS LT remains heterogeneously defined but characterized by high mortality rates despite the use of tailored surgical solutions (graft reduction and open abdomen). A composite definition is proposed in order to better describe LFS clinical syndrome.

Salvage with a Secondary Infrahepatic Cavocavostomy of the Occluded Modified Piggyback Anastomosis during Split Liver Transplantation: A Case Report

Hepatic venous outflow obstruction following liver transplantation is rare but disastrous. Here we described a 14-year-old boy who underwent a split right lobe liver transplantation with modified (side-to-side) piggyback technique which resulted in hepatic venous outflow obstruction. When the liver graft was lifted up, the outflow drainage returned to normal but when it was placed back into the abdomen, the outflow obstruction recurred. Because reanastomosis would have resulted in hepatic reischemia, alternatively, a second infrahepatic cavocavostomy was planned without requiring hepatic reischemia. During this procedure, the first assistant hung the liver up to provide sufficient outflow and the portal inflow of the graft continued as well. We only clamped the recipient's infrahepatic vena cava and the caudal cuff of the graft cava. After the second end-to-side cavocaval anastomosis, the graft was placed in its orthotopic position and there was no outflow problem anymore. The patient tolerated the procedure well and there were no problems after three months of follow-up. A second cavocavostomy can provide an extra bypass for some hepatic venous outflow problems after piggyback anastomosis by avoiding hepatic reischemia.