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Kawaguchi S, Onozawa S, Momose H, Matsuki R, Kogure M, Suzuki Y, Sakamoto Y. Rescue of outflow block of the remnant left liver after extended right hemihepatectomy for resection of a tumor in the caudate lobe. Glob Health Med 2024; 6:222-224. [PMID: 38947414 PMCID: PMC11197159 DOI: 10.35772/ghm.2023.01105] [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: 10/07/2023] [Revised: 02/08/2024] [Accepted: 02/29/2024] [Indexed: 07/02/2024]
Abstract
Outflow block of the liver is a life-threatening event after living donor liver transplantation. Herein, we rescued a patient suffering from the outflow block of the remnant left hemiliver caused by bending of the left hepatic vein (LHV) after right hemihepatectomy plus caudate lobectomy combined with resection of the middle hepatic vein (MHV). A metastatic tumor sized 6 cm in the caudate lobe of the liver involving the root of the MHV was found in a 50's year old patient after resection of a right breast cancer eight years ago. Right hemihepatectomy and caudate lobectomy combined with resection of the MHV was performed using a two-stage hepatectomy (partial TIPE ALPPS). On day 1, the total bilirubin value increased to 4.5 mg/dL, and a dynamic computed tomography (CT) scan showed the bent LHV. On the diagnosis of outflow block of the left liver, a self-expandable metallic stent was placed in the LHV using an interventional approach, and the pressure in the LHV decreased from 27 cmH2O to 12 cmH2O. The bilirubin value decreased to 1.2 mg/dL on day 3. Outflow block of the LHV can happen after extended right hemihepatectomy with resection of the MHV. Early diagnosis and interventional stenting treatment can rescue the patient from congestive liver failure.
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Affiliation(s)
- Shohei Kawaguchi
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Shiro Onozawa
- Department of Radiology, Kyorin University Hospital, Tokyo, Japan
| | - Hirokazu Momose
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Ryota Matsuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Masaharu Kogure
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Yutaka Suzuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
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Yan Y, Yang A, Lu L, Zhao Z, Li C, Li W, Chao J, Liu T, Fong Y, Fu W, Woo Y. Impact of Neoadjuvant Therapy on Minimally Invasive Surgical Outcomes in Advanced Gastric Cancer: An International Propensity Score-Matched Study. Ann Surg Oncol 2020; 28:1428-1436. [PMID: 32862371 DOI: 10.1245/s10434-020-09070-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND No international consensus on the treatment of advanced gastric cancer (AGC) exists. In the absence of well-designed, comparative studies between neoadjuvant versus adjuvant strategies, concerns about increased risk of postoperative complications remain barriers to neoadjuvant chemotherapy (NAC) for AGC. We evaluated surgical outcomes of AGC patients who received minimally invasive radical gastrectomy with D2 lymphadenectomy after NAC. METHODS We collected data from two high-volume gastric cancer programs in the United States and China between January 2015 and December 2019 with the last follow-up in February 2020. AGC patients undergoing minimally invasive radical surgery were included. After propensity score-matching, surgical outcomes were analyzed. Risk-factor of complications was analyzed in the whole cohort. RESULTS After 1:1 propensity score-matching, 97 patients were included in each cohort. NAC + surgery cohort was younger (58.2 ± 10.3 vs. 61.3 ± 9.6, P = 0.036) with lower preoperative WBC count (5.7 ± 2.8 vs. 6.9 ± 2.1 × 109/ml) than the surgery upfront cohort. NAC was not a risk-factor for postoperative complications (odds ratio [OR], 0.859; 95% confidence interval [CI], 0.46-1.60; P = 0.633). Overall risk-factors of postoperative complications included age ≥ 60 years (OR, 21.338; 95% CI, 5.00-91.05; P < 0.001), tumor size ≥ 5 cm (OR, 1.24; 95% CI, 1.08-1.83; P < 0.001), operation time ≥ 240 min (OR, 5.53; 95% CI, 1.26-24.26; P = 0.012), and ASA classification ≥ II (OR, 13.14; 95% CI, 4.12-24.73; P < 0.001). CONCLUSIONS NAC before minimally invasive radical gastrectomy with D2 lymphadenectomy does not increase postoperative complications, and these findings support broader application of NAC and MIS for AGC. Additional studies are required to determine the effect of NAC on long-term survival.
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Affiliation(s)
- Yongjia Yan
- Division of Surgical Oncology, Department of Surgery, City of Hope National Comprehensive Cancer Center, Duarte, CA, USA.,Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Annie Yang
- Division of Surgical Oncology, Department of Surgery, City of Hope National Comprehensive Cancer Center, Duarte, CA, USA
| | - Li Lu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhicheng Zhao
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Chuan Li
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Weidong Li
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Joseph Chao
- Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center, Duarte, CA, USA
| | - Tong Liu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuman Fong
- Division of Surgical Oncology, Department of Surgery, City of Hope National Comprehensive Cancer Center, Duarte, CA, USA
| | - Weihua Fu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China.
| | - Yanghee Woo
- Division of Surgical Oncology, Department of Surgery, City of Hope National Comprehensive Cancer Center, Duarte, CA, USA. .,Cancer Immunotherapeutics Program, Beckman Research Institute, City of Hope, Duarte, CA, USA.
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Ishii M, Mizuguchi T, Harada K, Ota S, Meguro M, Ueki T, Nishidate T, Okita K, Hirata K. Comprehensive review of post-liver resection surgical complications and a new universal classification and grading system. World J Hepatol 2014; 6:745-751. [PMID: 25349645 PMCID: PMC4209419 DOI: 10.4254/wjh.v6.i10.745] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 09/01/2014] [Accepted: 09/17/2014] [Indexed: 02/06/2023] Open
Abstract
Liver resection is the gold standard treatment for certain liver tumors such as hepatocellular carcinoma and metastatic liver tumors. Some patients with such tumors already have reduced liver function due to chronic hepatitis, liver cirrhosis, or chemotherapy-associated steatohepatitis before surgery. Therefore, complications due to poor liver function are inevitable after liver resection. Although the mortality rate of liver resection has been reduced to a few percent in recent case series, its overall morbidity rate is reported to range from 4.1% to 47.7%. The large degree of variation in the post-liver resection morbidity rates reported in previous studies might be due to the lack of consensus regarding the definitions and classification of post-liver resection complications. The Clavien-Dindo (CD) classification of post-operative complications is widely accepted internationally. However, it is hard to apply to some major post-liver resection complications because the consensus definitions and grading systems for post-hepatectomy liver failure and bile leakage established by the International Study Group of Liver Surgery are incompatible with the CD classification. Therefore, a unified classification of post-liver resection complications has to be established to allow comparisons between academic reports.
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Urahashi T, Mizuta K, Ihara Y, Sanada Y, Wakiya T, Yamada N, Okada N. Impact of post-transplant flow cytometric panel-reactive antibodies on late-onset hepatic venous outflow obstruction following pediatric living donor liver transplantation. Transpl Int 2014; 27:322-9. [DOI: 10.1111/tri.12255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 04/30/2013] [Accepted: 11/28/2013] [Indexed: 12/22/2022]
Affiliation(s)
- Taizen Urahashi
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Koichi Mizuta
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Yoshiyuki Ihara
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Yukihiro Sanada
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Taiichi Wakiya
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Naoya Yamada
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
| | - Noriki Okada
- Department of Transplant Surgery; Jichi Medical University; Shimotsuke-shi Japan
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5
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"Small-for-flow" syndrome: shifting the "size" paradigm. Med Hypotheses 2013; 80:573-7. [PMID: 23428310 DOI: 10.1016/j.mehy.2013.01.028] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 01/08/2013] [Accepted: 01/26/2013] [Indexed: 02/07/2023]
Abstract
The "small-for-size" syndrome and "post-hepatectomy liver failure" refers to the development of liver failure (hyperbilirubinemia, coagulopathy, encephalopathy and refractory ascites) resulting from the reduction of liver mass beyond a certain threshold. This complication is associated with a high mortality and is a major concern in liver transplantation involving reduced liver grafts from deceased and living donors as well as in hepatic surgeries involving extended resections of liver mass. The limiting threshold for liver resection or transplantation is currently predicted based on the mass of the remnant liver (or donor graft) in relation to the body weight of the patient, with a ratio above 0.8 being considered safe. This approach, however, has proved inaccurate, because some patients develop the "small-for-size" syndrome despite complying with the "safe" threshold while other patients who surpass the threshold do not develop it. We hypothesize that the development of the "small-for-size" syndrome is not exclusively determined by the ratio of the mass of the liver remnant (or graft) to the body weight, but it is instead strictly determined by the hemodynamic parameters of the hepatic circulation. This hypothesis is based in recent clinical and experimental reports showing that relative portal hyperperfusion is a critical factor in the development of the "small-for-size" syndrome and that maneuvers that manipulate the hepatic vascular inflow are able to prevent the development of the syndrome despite liver-to-body weight ratios well below the "limiting" threshold. Measurements of hepatic blood flow and pressure, however, are not routinely performed in hepatic surgeries. Focusing on the "flow" rather than in the "size" may improve our understanding of the pathophysiology of the "small-for-size" syndrome and "post-hepatectomy liver failure" and it would have important implications for the clinical management of patients at risk. First, hepatic hemodynamic parameters would have to be measured in hepatic surgeries. Second, these parameters (in addition to liver mass) would be the principal basis for deciding the "safe" threshold of viable liver parenchyma. Third, the hepatic hemodynamic parameters are amenable to manipulation and, consequently, the "safe" threshold may also be manipulated. Shifting the paradigm from "small-for-size" to "small-for-flow" syndrome would thus represent a major step for optimizing the use of donor livers, for expanding the indications of hepatic surgery, and for increasing the safety of these procedures.
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Urahashi T, Katsuragawa H, Yamamoto M, Ihara Y, Sanada Y, Wakiya T, Mizuta K. Use of 3-dimensional computed hepatic venous visualization for graft outflow venoplasty in adult left living-donor liver transplant. EXP CLIN TRANSPLANT 2012; 10:350-5. [PMID: 22845766 DOI: 10.6002/ect.2012.0075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES A surgeon must be aware of hepatic vascular variations to safely perform living-donor liver transplant. The ramification patterns of the hepatic veins with tributaries for left lobe graft outflow venoplasty should be evaluated preoperatively with 3-dimensional computed tomography of the donor. MATERIALS AND METHODS Twenty-four potential donors were examined between October 1999 and July 2006 for living-donor liver transplant using the left lobe. They underwent triphasic helical computed tomography of the liver on a multidetector helical computed tomographic scanner. All images, including 2-dimensional reformation and 3-dimensional reconstructed models with maximum intensity projection and volume rendering, were sent to a workstation for postprocessing. RESULTS The ramification patterns of the left and middle hepatic vein were classified into 2 groups; they formed a common trunk (type 1), which had 3 variations; type 1A (13 cases): in which the left hepatic vein and the middle hepatic vein without any tributaries on their confluence; type 1B (8 cases): in which there was venous confluence in the left hepatic vein with the left superficial vein and middle hepatic vein; type 1C (2 cases): in which the hepatic venous confluence in the left hepatic vein and middle hepatic vein and the left superficial vein directly joining into the inferior vena cava; type 2 (1 case) had the left hepatic vein and middle hepatic vein joining into the inferior vena cava separately; type 1B underwent 2 venoplasty procedures, but the others underwent only a single venoplasty. CONCLUSIONS We demonstrated the anatomic interrelation of the hepatic veins for hepatic outflow venoplasty of adult left lobe living-donor liver transplant with 3-dimensional computed tomography scanning to help surgeons preoperatively determine the appropriate technique or form of reconstruction.
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Affiliation(s)
- Taizen Urahashi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.
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Mori A, Kaido T, Ogura Y, Ogawa K, Hata K, Yagi S, Yoshizawa A, Isoda H, Shibata T, Uemoto S. Standard hepatic vein reconstruction with patch plasty using the native portal vein in adult living donor liver transplantation. Liver Transpl 2012; 18:602-7. [PMID: 22253117 DOI: 10.1002/lt.23387] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
An outflow obstruction of the hepatic vein is a critical complication after living donor liver transplantation (LDLT) and occasionally leads to hepatic failure. Here we introduce a simple method for preventing outflow obstructions by patch plasty in adult LDLT. Between September 2001 and May 2010, 468 adult LDLT procedures were performed at Kyoto University Hospital. We harvested each recipient's portal vein (PV) from the extirpated liver for a patch. We intended to re-form several orifices of the hepatic veins into a single, large orifice. The patch was attached to the anterior wall of the re-formed orifice on the bench. After we put in the liver graft, the procedure for the hepatic vein anastomosis to the inferior vena cava was simple enough that the warm ischemia time was reduced. Three of the 468 cases were diagnosed with an outflow obstruction. All 3 cases underwent hepatic vein reconstruction without patch plasty. In contrast, none of the 159 cases that underwent LDLT with patch plasty suffered from an outflow obstruction, regardless of the liver graft type. The procedure for hepatic vein plasty using a patch from the native PV is simple and elegant and results in excellent outcomes. We propose this as the standard procedure for hepatic vein reconstruction in adult LDLT.
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Affiliation(s)
- Akira Mori
- Department of Surgery (Division of Hepato-Biliary-Pancreatic Surgery and Transplantation)Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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8
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Sakamoto S, Egawa H, Kanazawa H, Shibata T, Miyagawa-Hayashino A, Haga H, Ogura Y, Kasahara M, Tanaka K, Uemoto S. Hepatic venous outflow obstruction in pediatric living donor liver transplantation using left-sided lobe grafts: Kyoto University experience. Liver Transpl 2010; 16:1207-14. [PMID: 20879019 DOI: 10.1002/lt.22135] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The goals of this study were to evaluate the incidence of hepatic venous outflow obstruction (HVOO) in pediatric patients after living donor liver transplantation (LDLT) using left-sided lobe grafts and to assess the therapeutic modalities used for the treatment of this complication at a single center. Four hundred thirteen primary LDLT procedures were performed with left-sided lobe grafts between 1996 and 2006. All transplants identified with HVOO from a cohort of 380 grafts with survival greater than 90 days were evaluated with respect to the patient demographics, therapeutic intervention, recurrence, and outcome. Seventeen cases (4.5%) were identified with HVOO. Eight patients experienced recurrence after the initial balloon venoplasty. Two patients finally required stent placement after they experienced recurrence shortly after the initial balloon venoplasty. A univariate analysis revealed that a smaller recipient-to-donor body weight ratio and the use of reduced grafts were statistically significant risk factors. The cases with grafts with multiple hepatic veins had a higher incidence of HVOO. In conclusion, the necessity of repeated balloon venoplasty and stent placement was related to poor graft survival. Therefore, the prevention of HVOO should be a high priority in LDLT. When grafts with multiple hepatic veins and/or significant donor-recipient size mismatching are encountered, the use of a patch graft is recommended. Stent placement should be carefully considered because of the absence of data on the long-term patency of stents and stent-related complications. New stenting devices, such as drug-eluting and biodegradable stents, may be promising for the management of HVOO.
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Affiliation(s)
- Seisuke Sakamoto
- Departments of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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9
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Shirouzu Y, Ohya Y, Hayashida S, Asonuma K, Inomata Y. Difficulty in sustaining hepatic outflow in left lobe but not right lobe living donor liver transplantation. Clin Transplant 2010; 25:625-32. [PMID: 20718823 DOI: 10.1111/j.1399-0012.2010.01322.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatic outflow block is one of the major complications leading to severe graft dysfunction after left lobe living donor liver transplantation (LDLT). METHODS Medical records of 46 recipients of a left lobe LDLT were reviewed. The method of outflow reconstruction and post-transplant morphological changes of hepatic veins were investigated. The subjects were followed up until September 2008, with a median follow-up period of 2.0 yr (range: 0.5-5.9 yr). RESULTS There were no multiple outflow tracts to be reconstructed, and the median caliber of the single orifices with or without venoplasty was 32.0 mm. The difference between the angle of hepatic veins to the sagittal plane measured on computed tomography was calculated for pre-operative donors and post-operative recipients a month after LDLT. Both left and middle hepatic veins showed a significantly greater change in angle than the right hepatic vein. Both left and middle hepatic veins more frequently showed a nearly flat wave form on Doppler study one month after LDLT. In the 46 recipients of left lobe grafts, three developed outflow block (6.5%). CONCLUSIONS The middle and left hepatic veins tend to distort and stretch during graft regeneration. These characteristics seem to be associated with outflow disturbances.
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Affiliation(s)
- Yasumasa Shirouzu
- Department of Transplantation and Pediatric Surgery, Postgraduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, Japan.
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10
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Ikegami T, Shimada M, Imura S, Arakawa Y, Nii A, Morine Y, Kanemura H. Current concept of small-for-size grafts in living donor liver transplantation. Surg Today 2008; 38:971-82. [PMID: 18958553 DOI: 10.1007/s00595-008-3771-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2007] [Accepted: 02/18/2008] [Indexed: 12/16/2022]
Abstract
The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called "small-for-size (SFS) graft syndrome." The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extension to include a right lobe graft. Clinical cases of living right lobe donations have been reported since then, drawing attention to the risks of increasing the liver volume procured from a living donor. However, not only other modes of increasing graft volume such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by an SFS graft, such as a portosystemic shunt or splenectomy, have been trialed with some positive results. To establish an effective strategy for transplanting SFS grafts and preventing SFS graft syndrome, it is essential to have precise knowledge and tactics to evaluate graft quality and graft volume, when performing these LDLTs with portal pressure control. We reviewed the updated literature on the pathogenesis of and strategies for using SFS grafts.
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Affiliation(s)
- Toru Ikegami
- Department of Surgery, University of Tokushima, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
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11
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Kilic M, Aydinli B, Aydin U, Alper M, Zeytunlu M. A new surgical technique for hepatic vein reconstruction in pediatric live donor liver transplantation. Pediatr Transplant 2008; 12:677-81. [PMID: 18208439 DOI: 10.1111/j.1399-3046.2007.00877.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The hepatic venous reconstruction is one of the corner stones of pediatric LDLT. However, problems associated with hepatic venous outflow still remain to be an issue. In this study, we aimed at comparing two methods used in hepatic venous reconstruction. Between November 1999 and December 2006, 61 consecutive left lateral segment pediatric LDLT were performed at Ege University Organ Transplant Center, and two methods were used for hepatic venous reconstruction. In the former group (group 1: 32 patients) continuous anastomosis was performed between the donor LHV and common orifice of the recipient HV. In the later group (group 2: 29 patients), the posterior wall of the anastomosis was sutured continuously while the anterior wall was sutured with interrupted sutures. HV thrombosis was detected in one patient and stenosis was detected in four patients in group 1. No hepatic venous outflow obstruction was detected in group 2 (p < 0.05). In both groups, mortality was not associated with hepatic venous outflow obstruction. As our results indicate, the novel technique used in this study is a simple and safe anastomosis procedure that has contributed into overcoming hepatic venous outflow problems in pediatric LDLT.
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Affiliation(s)
- Murat Kilic
- Department of Surgery, Ege University Hospital, Bornova, Izmir, Turkey.
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12
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Imura S, Shimada M, Ikegami T, Morine Y, Kanemura H. Strategies for improving the outcomes of small-for-size grafts in adult-to-adult living-donor liver transplantation. ACTA ACUST UNITED AC 2008; 15:102-10. [PMID: 18392702 DOI: 10.1007/s00534-007-1297-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 12/10/2007] [Indexed: 02/07/2023]
Abstract
Living-donor liver transplantation (LDLT) has been refined and accepted as a valuable treatment for patients with end-stage liver disease in order to overcome the shortage of organs and mortality on the waiting list. However, graft size problems, especially small-for-size (SFS) grafts, remain the greatest limiting factor for the expansion of LDLT, especially in adult-to-adult transplantation. Various attempts have been made to overcome the problems regarding SFS grafts, such as increasing the graft liver volume and/or controlling excessive portal inflow to a small graft, with considerable positive outcomes. Recent innovations in basic studies have also contributed to the treatment of SFS syndrome. Herein, we review the literature and assess our current knowledge of the pathogenesis and treatment strategies for the use of SFS grafts in adult-to-adult LDLT.
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Affiliation(s)
- Satoru Imura
- Department of Surgery, Institute of Health Biosciences, The University of Tokushima, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan
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13
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Shirouzu Y, Kasahara M, Morioka D, Sakamoto S, Taira K, Uryuhara K, Ogawa K, Takada Y, Egawa H, Tanaka K. Vascular reconstruction and complications in living donor liver transplantation in infants weighing less than 6 kilograms: the Kyoto experience. Liver Transpl 2006; 12:1224-32. [PMID: 16868949 DOI: 10.1002/lt.20800] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Smaller-size infants undergoing living-donor liver transplantation (LDLT) are at increased risks of vascular complications because of their smaller vascular structures in addition to vascular pedicles of insufficient length for reconstruction. Out of 585 child patients transplanted between June 1990 and March 2005, 64 (10%) weighing less than 6 kg underwent 65 LDLTs. Median age and weight were 6.9 months (range: 1-16 months) and 5 kg (range: 2.8-5.9 kg), respectively. Forty-five lateral segment, 12 monosegment, and 8 reduced monosegment grafts were adopted, and median graft-to-recipient weight ratio was 4.4% (range: 2.3-9.7). Outflow obstruction occurred in only 1 patient (1.5%). Portal vein complication occurred in 9 (14%) including 5 with portal vein thrombosis. Hepatic artery thrombosis (HAT) occurred in 5 (7.7%). Patient and graft survivals were 73% and 72% at 1 yr, and 69% and 68% at 5 yr after LDLT, respectively. Thirteen of 22 grafts (58%) lost during the follow-up period occurred within the first 3 months posttransplantation. Overall graft survival in patients with and without portal vein complication was 67% and 65%, respectively (P = 0.54). Overall graft survival in patients with and without HAT was 40% and 67%, respectively. HAT significantly affected graft survival (P = 0.04). In conclusion, our surgical technique for smaller-size recipients resulted in an acceptable rate of vascular complications. Overcoming early posttransplantation complications will further improve outcomes in infantile LDLT.
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Affiliation(s)
- Yasumasa Shirouzu
- Departments of Transplant Surgery, Kyoto University Hospital, Kyoto, Japan.
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14
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Kogure K, Ishizaki M, Nemoto M, Kuwano H, Yorifuji H, Takata K, Ishikawa H, Makuuchi M. Morphogenesis of an anomalous ligamentum venosum terminating in the superior left hepatic vein in a human liver. ACTA ACUST UNITED AC 2006; 12:310-3. [PMID: 16133698 DOI: 10.1007/s00534-005-0987-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2005] [Accepted: 03/24/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE We aimed to clarify the morphogenesis of an anomalous ligamentum venosum terminating in the trunk of the superior left hepatic vein, because the ligamentum venosum ordinarily terminates into the root of the left hepatic vein or directly into the inferior vena cava. METHODS We examined an anomalous ligamentum venosum found in the cadaveric liver of an 84-year-old Japanese woman. RESULTS The ligamentum venosum in this liver was not found in the usual course, the fissure for the ligamentum venosum. It lay on the posterior surface of the liver, connecting the left branch of the portal vein and the trunk of a small left hepatic vein. The small left hepatic vein draining the cranio-dorsal part of the lateral segment of the liver was revealed to be a superior left hepatic vein. This type of anomaly was found only in this 1 liver, among 125 cadaveric livers that were dissected. CONCLUSIONS Taking previous reports into consideration, the morphogenesis of the anomalous ligamentum venosum in the present case may be explained as being due to the persistence of the right half of the subdiaphragmatic anastomosis, which receives the blood from the ductus venosus in the embryonal period.
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Affiliation(s)
- Kimitaka Kogure
- Department of General Surgical Science (Surgery I), Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi 371-8511, Japan
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15
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Sato K, Sekiguchi S, Akamatsu Y, Kawagishi N, Enomoto Y, Iwane T, Sato A, Fujimori K, Satomi S. Liver laceration associated with severe seizures after living donor liver transplantation. Liver Transpl 2006; 12:152-5. [PMID: 16382468 DOI: 10.1002/lt.20629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hemorrhagic complications commonly occur early after liver transplantation (LT), sometimes requiring emergent relaparotomy. However, active bleeding from the liver graft itself is a rare but life-threatening complication after living donor liver transplantation (LDLT). We report an unusual case of liver laceration with massive bleeding, associated with severe epileptic seizures as a result of tacrolimus-induced leukoencephalopathy, after LDLT. The patient was successfully rescued by conventional surgical management without a second transplantation. In conclusion, to our knowledge this is the first reported case of graft rupture due to immunosuppression-associated leukoencephalopathy after LT.
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Affiliation(s)
- Kazushige Sato
- Advanced Surgical Science and Technology Division, Department of Surgery, Graduate School of Medicine, University of Tohoku, Sendai, Japan.
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Suehiro T, Shimada M, Kishikawa K, Shimura T, Soejima Y, Yoshizumi T, Hashimoto K, Mochida Y, Maehara Y, Kuwano H. Impact of Graft Hepatic Vein Inferior Vena Cava Reconstruction with Graft Venoplasty and Inferior Vena Cava Cavoplasty in Living Donor Adult Liver Transplantation Using a Left Lobe Graft. Transplantation 2005; 80:964-8. [PMID: 16249746 DOI: 10.1097/01.tp.0000173776.66867.f5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Hepatic venous reconstruction is critical in living donor adult liver transplantation (LDALT) because outflow obstruction in small for size graft may lead to graft dysfunction or loss. We describe the usefulness of venoplasties of the graft hepatic vein (HV) and graft HV-recipient inferior vena cava (IVC) reconstruction in LDALT using a left lobe graft. METHODS Sixty patients who underwent LDALT were studied. We divided the patients into following two groups: venoplasty group (n=30) and control group (n=30). For the patients with venoplasty group, venoplasty of the graft and recipient IVC cavoplasty was made to widen the orifice. Comparison examination of a background factors and postoperative bilirubin and the ascites was carried out. RESULTS The mean graft volume standard liver volume ratio (GV/SLV) did not have the difference at 41.7% of venoplasty group, and 42.1% of control group (p=NS). The diameter of the hepatic vein in control and venoplasty group before and after venoplasty is 26.9+/-5.5, 28.2+/-2.9, and 34.1+/-3.9 mm, respectively. The diameter of the hepatic vein after venoplasty is larger than that of before venoplasty and of control (P<0.05). Mean total bilirubin level on postoperative day (POD) 7 is 13.8+/-9.3 mg/dl in control group and 7.0+/-3.3 mg/dl in venoplasty group (P<0.05). Mean amount of ascites on POD 7 and 14 are 1576+/-1113 and 1397+/-1661 cc in control group, and 736+/-416 and 550+/-385 cc in venoplasty group, respectively (P<0.05). Two-year survival rate is 75.2 % in control group and 86.6 % in venoplasty group (P<0.05). CONCLUSIONS We conclude that in LDALT using left lobe graft, HV-IVC reconstruction with graft venoplasty and IVC cavoplasty is useful not only to prevent outflow block but also to improve graft function.
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Affiliation(s)
- Taketoshi Suehiro
- Department of General Surgical Science, and the 21st Century COE Program, Graduate School of Medicine, Gunma University, Maebashi, Japan.
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Tannuri U, Mello ES, Carnevale FC, Santos MM, Gibelli NE, Ayoub AA, Maksoud-Filho JG, Velhote MCP, Silva MM, Pinho ML, Miyatani HT, Maksoud JG. Hepatic venous reconstruction in pediatric living-related donor liver transplantation--experience of a single center. Pediatr Transplant 2005; 9:293-8. [PMID: 15910383 DOI: 10.1111/j.1399-3046.2005.00306.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In pediatric patients submitted to living related liver transplantation, hepatic venous reconstruction is critical because of the diameter of the hepatic veins and the potential risk of twisting of the graft over the line of the anastomosis. The aim of the present study is to present our experience in hepatic venous reconstruction performed in pediatric living related donor liver transplantation. Fifty-four consecutive transplants were performed and two methods were utilized for the reconstruction of the hepatic vein: direct anastomosis of the orifice of the donor left or left and middle hepatic veins and the common orifice of the recipient left and middle hepatic veins (group 1-26 cases), and wide triangular anastomosis after creating a wide triangular orifice in the recipient inferior vena cava at the confluence of all the hepatic veins with an additional longitudinal incision in the inferior angle of the orifice (group 2-28 cases). In group 1, eight patients were excluded because of graft problems in the early postoperative period and five among the remaining 18 patients (27.7%) presented stricture at the site of the hepatic vein anastomosis. All these patients had to be submitted to two or three sessions of balloon dilatations of the anastomoses and in four of them a metal stent had to be placed. The liver histopathological changes were completely reversed by the placement of the stent. Among the 28 patients of the group 2, none of them presented hepatic vein stenosis (p = 0.01). The results of the present series lead to the conclusion that hepatic venous reconstruction in pediatric living donor liver transplantation must be preferentially performed by using a wide triangulation on the recipient inferior vena cava, including the orifices of the three hepatic veins. In cases of stenosis, the endovascular dilatation is the treatment of choice followed by stent placement in cases of recurrence.
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Affiliation(s)
- Uenis Tannuri
- Liver Transplantation Unit, Children Institute, Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil.
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Takemura N, Sugawara Y, Hashimoto T, Akamatsu N, Kishi Y, Tamura S, Makuuchi M. New hepatic vein reconstruction in left liver graft. Liver Transpl 2005; 11:356-60. [PMID: 15719404 DOI: 10.1002/lt.20374] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The incidence of hepatic venous stenosis is higher in partial liver transplantation. New methods for hepatic venous reconstruction in left liver transplantation, which secure wide anastomosis, were devised and are reported here. In the graft, the right side of the middle hepatic vein or the left side of the left hepatic vein was cut longitudinally and a rectangular-shaped vein patch was attached for venoplasty. In the recipient, after the left and middle hepatic veins were joined, the right side of the middle hepatic vein was cut toward the closed right hepatic vein, making a horizontal cavotomy for anastomosis. Of 92 patients who underwent conventional hepatic vein reconstruction, 3 were complicated by hepatic venous stenosis (median follow-up 43 months). By contrast, there were no hepatic vein complications in the 20 patients who underwent the new technique (7 months). The current method appears to be technically feasible for outflow reconstruction in left liver graft transplantation.
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Affiliation(s)
- Nobuyuki Takemura
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Yamanaka J, Imamura M, Kuroda N, Hirano T, Fujimoto J. Hepatic venoplasty to overcome outflow block in living related liver transplantation. J Pediatr Surg 2004; 39:1128-9. [PMID: 15213915 DOI: 10.1016/j.jpedsurg.2004.03.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A 14-year-old boy with congenital biliary atresia underwent living related liver transplantation. Because of anatomic variation in donor hepatic vein, there were small and double orifices of hepatic veins in the harvested left hemiliver graft. To minimize the risk of outflow block after reperfusion, the recipient's native hepatic vein was used as an autologous patch for hepatic vein reconstruction. After 3 years of follow-up, the patient is alive and well with normal liver function. Follow-up duplex ultrasound scan showed adequate hepatic vein outflow without signs of late obstruction. The new technique of the autologous vascular patch grafting for successful hepatic vein reconstruction is described.
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Affiliation(s)
- Junichi Yamanaka
- First Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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Fan ST, Lo CM, Liu CL, Yong BH, Wong J. Determinants of hospital mortality of adult recipients of right lobe live donor liver transplantation. Ann Surg 2003; 238:864-69; discussion 869-70. [PMID: 14631223 PMCID: PMC1356168 DOI: 10.1097/01.sla.0000098618.11382.77] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To define the technical factors that might contribute to hospital mortality of recipients of right lobe live donor liver transplantation (LDLT) so as to perfect the design of the operation. SUMMARY BACKGROUND DATA Right lobe LDLT has been accepted as one of the treatments for patients with terminal hepatic failure, but the design and results of the reported series vary and the technical factors affecting hospital mortality have not been known. METHODS The data of 100 adult-to-adult right lobe LDLT performed between 1996 and 2002 were prospectively collected and retrospectively analyzed. All grafts except one contained the middle hepatic vein, which was anastomosed to the recipient middle/left hepatic vein in the first 84 recipients and directly into the inferior vena cava (with the right hepatic vein in form of venoplasty) in the subsequent 15 patients. Venovenous bypass was used routinely in the first 29 patients but not subsequently. RESULTS Eight patients died within the same hospital admission for liver transplantation. There was no hospital mortality in the last 53 recipients. Comparison of data of patients with or without hospital mortality showed that graft weight/body weight ratio, graft weight/estimated standard liver weight ratio, technical error resulting in occlusion/absence of the middle hepatic vein, use of venovenous bypass, the lowest body temperature recorded during surgery, the volume of intraoperative blood transfusion, fresh frozen plasma, and platelet infusion were significantly different between the two groups. However, the pretransplant intensive care unit status of the recipients, cold and warm ischemic time of the graft, and occurrence of biliary complications were not. By multivariate analysis, low body temperature recorded during operation, low graft weight/estimated standard liver weight ratio (</=0.35), and the middle hepatic vein occlusion were independent significant factors in determining hospital mortality. CONCLUSIONS To achieve a uniformly successful right lobe LDLT, the right lobe graft must contain a patent middle hepatic vein. With a completely patent middle hepatic vein, a graft size of >35% of the estimated standard graft weight may be sufficient for recipient survival. Hypothermia, which predisposes to coagulopathy and is enhanced by the use of venovenous bypass and massive blood, and blood product transfusion must be avoided.
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Affiliation(s)
- Sheung-Tat Fan
- Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
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Abstract
Inclusion of the middle hepatic vein (MHV) in a right lobe graft is essential to guarantee uniform venous drainage and optimum function of the graft, but end-to-end recipient-to-donor MHV anastomosis may result in outflow obstruction. To avoid outflow obstruction, we designed the venoplasty technique. From September 2000 to November 2002, 65 adult patients received right lobe live donor liver transplantation (LDLT) with grafts containing the right hepatic vein (RHV) and MHV. In the first 34 recipients, the graft RHV and MHV were anastomosed to the recipients' RHV and MHV/left hepatic vein, respectively. For the subsequent 31 recipients, the MHV was joined to the RHV at the back table to form a triangular common orifice. The septum in between the two hepatic veins was divided at the middle and sutured transversely to remove the ridge in between and to create a large opening. The common orifice was anastomosed to a matched-size triangular opening in the recipient's inferior vena cava. After reperfusion, the presence of triphasic pulsatility on spectral Doppler tracing was regarded as a sign of perfect reconstruction. In the first group, Doppler study showed little flow in the MHV in 3 patients, absent pulsatility in the MHV after portal vein reperfusion in 4 patients, and absent pulsatility in the MHV after hepatic artery reperfusion in 5 patients. In the second group, excellent triphasic pulsatility was seen in all except 1 patient (12 of 34 versus 1 of 31, P =.001). A significant increase in the peak flow velocity was seen in the MHV in the second group (median, 19.45 cm/sec versus 31.4 cm/sec, P<.001). Less time was required to complete the hepatic vein anastomoses in the second group (40 minutes versus 27 minutes, P<.001). In conclusion, hepatic venoplasty technique facilitates the implantation of the right lobe graft and guarantees outflow in the MHV.
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Affiliation(s)
- Chi-Leung Liu
- Centre for the Study of Liver Disease and Department of Surgery, The University of Hong Kong, Pokfulam, Hong Kong, China
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Makuuchi M, Sugawara Y. Living-donor liver transplantation using the left liver, with special reference to vein reconstruction. Transplantation 2003; 75:S23-4. [PMID: 12589134 DOI: 10.1097/01.tp.0000046617.21019.17] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors describe their techniques for hepatic vein reconstruction, devised for safe living-donor liver transplantation using a left liver graft. End-to-end anastomosis of the hepatic veins is performed to prevent an outflow occlusion. To ensure adequate hepatic venous flow, it is necessary to obtain a wide ostium and sufficient length of the hepatic vein for anastomosis, which should be secured by venoplasty of the hepatic veins of the graft and the recipient. A left liver with a caudate lobe graft is useful for overcoming the problem of a small graft. Reconstruction of the short hepatic vein of the caudate lobe may allow this portion to regenerate at the same rate as the left liver. In a left liver graft without the trunk of the middle hepatic vein, reconstruction of a tributary of this vein might be necessary to prevent graft congestion in segment IV. Color Doppler ultrasonography or a hepatic arterial clamping test should be performed in donor hepatectomy to evaluate the need for middle hepatic vein reconstruction.
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Affiliation(s)
- Masatoshi Makuuchi
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
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Majno PE, Mentha G, Morel P, Segalin A, Azoulay D, Oberholzer J, Le Coultre C, Fasel J. Arantius' ligament approach to the left hepatic vein and to the common trunk. J Am Coll Surg 2002; 195:737-9. [PMID: 12437267 DOI: 10.1016/s1072-7515(02)01324-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Pietro E Majno
- Department of Surgery, University Hospitals, Geneva, Switzerland
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Dasarathy S, Mullen KD. Hepatic Encephalopathy. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2001; 4:517-526. [PMID: 11696278 DOI: 10.1007/s11938-001-0017-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A characteristic feature of the neuropsychiatric changes in hepatic encephalopathy (HE) is the potential for a complete recovery in the majority of patients. In this review, we limit our discussion to HE in individuals with chronic liver disease. The optimal approach to the management of HE includes the following elements. Provide standard supportive therapy for patients with an altered mental status. This is the mainstay of therapy in the majority of clinical situations and includes administration of parenteral fluids and nutrition, care of vascular and bladder catheters, control of self-injurious activities, and instituting aspiration precautions. Rule out or control concomitant causes of encephalopathy. The diagnosis of HE has positive and negative criteria, and ruling out other causes of change in mental status is an essential component of the diagnosis. Identify and correct the precipitating factors of HE. In the majority of patients with HE, a clearly defined precipitating factor usually is identified, and the reversal or control of these factors is a key step in management. Institute gut-cleansing and ammonia-lowering measures. These measures are based on clinical and pathogenic characteristics of HE and are aimed at neutralizing the putative encephalogenic toxins (namely ammonia).
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Affiliation(s)
- Srinivasan Dasarathy
- Gastrointestinal Division, Department of Medicine, MetroHealth Medical Center, 2500 MetroHealth Drive, Bell Greve Building, Cleveland, OH 44109-1998, USA.
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Living donor liver transplantation: donor selection, evaluation, and surgical complications. Curr Opin Organ Transplant 2001. [DOI: 10.1097/00075200-200106000-00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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