Liver Transplantation in an Adult Recipient With Situs Inversus Totalis: Case Report and Review of the Literature

Liver and pancreas transplantation in adult donor and recipients with situs inversus totalis: a case series and review of the literature

BACKGROUND

Situs inversus totalis is a rare congenital anomaly characterized by a mirror-image orientation of abdominal, and in some cases, thoracic organs. Here, we report our situs inversus totalis transplantation experience and further review liver transplantations in adult recipients and donors with situs inversus totalis.

CASE PRESENTATION

We describe three cases with situs inversus totalis. The first case was liver transplantation in a recipient (a 61-year-old Iranian man) with situs inversus totalis, the second was a liver transplantation from a donor (a 52-year-old Iranian woman) with situs inversus totalis, and finally, for the first time, a simultaneous pancreas and kidney transplantation in a recipient (a 26-year-old Iranian man) with situs inversus totalis. In patient one, hepatectomy could be performed according to the standard method and on the basis of preoperative studies. Hepatic vein and arterial anastomosis were performed as in every other patient without situs inversus totalis. To prevent biliary complications, a Roux-en-Y hepaticojejunostomy was performed. In patient two, implantation time, suprahepatic vein, portal vein, arterial, and biliary reconstruction could be done as in any other case without situs inversus totalis. Plication of the right-sided diaphragm and fixation of the falciform ligament was done for our patient. In patient three, systemic drainage was preferred to portal flow for establishing the outflow drainage of the pancreas compared with otherwise normal patients.

CONCLUSION

Although situs inversus totalis is a rare condition, our reported techniques are suitable, considering advantages such as easier accessibility, more acceptable placement of the implanted organs regarding vascular variations, and the appropriate location of the allograft in the proximity of other organs.

BILE DUCT INJURY REPAIR IN A PATIENT WITH SITUS INVERSUS TOTALIS

BACKGROUND

Bile duct injury (BDI) causes significant sequelae for the patient in terms of morbidity, mortality, and long-term quality of life, and should be managed in centers with expertise. Anatomical variants may contribute to a higher risk of BDI during cholecystectomy.

AIMS

To report a case of bile duct injury in a patient with situs inversus totalis.

METHODS

A 42-year-old female patient with a previous history of situs inversus totalis and a BDI was initially operated on simultaneously to the lesion ten years ago by a non-specialized surgeon. She was referred to a specialized center due to recurrent episodes of cholangitis and a cholestatic laboratory pattern. Cholangioresonance revealed a severe anastomotic stricture. Due to her young age and recurrent cholangitis, she was submitted to a redo hepaticojejunostomy with the Hepp-Couinaud technique. To the best of our knowledge, this is the first report of BDI repair in a patient with situs inversus totalis.

RESULTS

The previous hepaticojejunostomy was undone and remade with the Hepp-Couinaud technique high in the hilar plate with a wide opening in the hepatic confluence of the bile ducts towards the left hepatic duct. The previous Roux limb was maintained. Postoperative recovery was uneventful, the drain was removed on the seventh post-operative day, and the patient is now asymptomatic, with normal bilirubin and canalicular enzymes, and no further episodes of cholestasis or cholangitis.

CONCLUSIONS

Anatomical variants may increase the difficulty of both cholecystectomy and BDI repair. BDI repair should be performed in a specialized center by formal hepato-pancreato-biliary surgeons to assure a safe perioperative management and a good long-term outcome.

Deceased donor liver transplantation in an adult recipient with situs inversus totalis: A case report of 10-year clinical sequences following primary and repeat transplantation

The feasibility of liver transplantation (LT) in adult patients with situs inversus (SI) was demonstrated with advances in surgical techniques. However, SI is very rare, and the experience of LT in adult patients with SI is very limited. We present a case of an adult patient with SI who underwent deceased-donor LT and late retransplantation because of chronic rejection. A 42-year-old man with SI totalis who suffered from acute-on-chronic hepatic failure because of hepatitis B virus-associated liver cirrhosis and alcoholic liver disease was referred to our center and underwent successful orthotopic deceased-donor whole-liver transplantation. We used a modified piggy-back technique with cavo-cavostomy and inserted a tissue expander for mechanical support of the unstably located liver graft. The patient recovered uneventfully. At 3 years after the first LT, this patient underwent retransplantation because of chronic rejection. In the second LT, we used similar surgical techniques, but performed splenectomy to make space to accommodate the second liver graft. The patient was discharged after long hospitalization. At 5 years after the second LT, he underwent living-donor kidney transplantation because of chronic renal failure developed after the second LT. Currently, he has done well for 10 years after the first LT. In conclusion, SI is a rare anomalous condition hindering LT. Careful perioperative planning with thorough assessment of the donor and recipient livers and use of patient-tailored surgical techniques can lead to successful LT.

Living donor liver transplantation in situs inversus totalis with a patient-specific three-dimensional printed liver model

We utilized patient-specific 3D liver models based on preoperative computed tomography images as intraoperative navigation and describe our experience. A 1-year and 10-month-old girl with situs inversus totalis underwent living donor liver transplantation for biliary atresia. Information on the hepatic artery, portal vein, inferior vena cava, and liver parenchyma was extracted and segmented from computed tomography images using liver analysis software. Laser lithography produced each 3D part of the liver from these data. The 3D models of each part of the liver were molded from polyurethane resin using different colors for each part and combined together, resulting in a patient-specific liver model. The industrial computed tomography scan of the patient-specific 3D liver model revealed that the gaps between the liver model and the original data were <0.4 mm in the 90% area, <0.8 mm in the 98% area, and 1.53 mm at the maximum. The 3D liver model was brought into the operative field and used as intraoperative navigation for total liver resection. The procedure was finished successfully without any major intraoperative complications. In conclusion, the 3D model facilitates the identification of vessels during operations; it is possible to promptly share patients' anatomy with the operative team.

Comorbidities in situs inversus totalis: A hospital-based study

BACKGROUND AND OBJECTIVE

Few studies have assessed the comorbid diseases in situs inversus totalis (SIT) comprehensively. The aim of this study was to provide insight into the spectrum and prevalence of comorbidities in SIT.

METHODS

Children ≤18 years of age with SIT were enrolled in this retrospective observational study. Situs status and comorbidities were independently confirmed by two physicians, based on review of radiologic, ultrasonic examination, operative records, and case notes.

RESULTS

A total of 155 children (median age: 1.24 years; range: 1 day-17.8 years) confirmed to have SIT were recruited between January 2008 and December 2018. Associated conditions were diagnosed in 114 children (73.5%). Among them, 25 children (16.1%) had multiple anomalies affecting two or more organ systems. The most commonly associated conditions were congenital heart defects (n = 72, 46.5%) followed by primary ciliary dyskinesia (n = 19, 12.3%), renal disorders (n = 12, 7.7%), biliary atresia (n = 7, 4.5%), skeletal dysplasia (n = 8, 5.2%), and mental retardation (n = 4, 2.6%).

CONCLUSION

A substantial proportion of children with SIT have comorbidities affecting multiple systems, especially cardiovascular and respiratory abnormalities. Children with SIT warrant careful examination for the presence of congenital and acquired abnormalities.