1
|
Huang S, Fahradyan A, Ahearn A, Kaur N, Sher L, Genyk Y, Emamaullee J, Patel K, Carey JN. Arterial Anastomosis Using Microsurgical Techniques in Adult Live Donor Liver Transplant: A Focus on Technique and Outcomes at a Single Institution. J Reconstr Microsurg 2023; 39:70-80. [PMID: 35764300 DOI: 10.1055/s-0042-1749339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Microvascular hepatic artery reconstruction (MHAR) is associated with decreased rates of hepatic artery thrombosis (HAT) in living donor liver transplantation (LDLT). There is a paucity of literature describing the learning points and initiation of this technique at the institutional level. The objective of this study is to report our institutional experience using MHAR in adult LDLT with a focus on technique and outcomes. METHODS A retrospective review of adult patients who underwent LDLT from January 2012 to December 2020 was conducted. Patients were divided into two groups, those who underwent LDLT without MHAR and with MHAR. We analyzed cases for technical data including donor and recipient artery characteristics, anastomotic techniques, intraop events, and postop complications. A Mann-Whitney test was performed to compare outcomes between non-MHAR and MHAR patients. RESULTS Fifty non-MHAR and 50 MHAR patients met inclusion criteria. Median age at transplantation was 58 (interquartile range [IQR] 11.8) and 57.5 years (IQR 14.5), respectively. Median follow-up for MHAR patients was 12.8 months (IQR 11.6). The most common recipient arteries were the right hepatic artery (HA) (58%) and left HA (20%). Median size of recipient and donor arteries were 3.3 mm (IQR 0.7) and 3.1 mm (IQR 0.7), resulting in a median mismatch size of 0.3 mm (IQR 0.4). Median microanastomosis time was 44 minutes (IQR 0). HAT, graft failure, and mortality rates were higher in the non-MHAR cohort (6% vs. 0%, 8% vs. 0%, and 16% vs. 6%, respectively); however, these did not reach statistical significance. CONCLUSION This study found lower rates of HAT and graft failure after implementing MHAR, though statistical significance was not achieved. Larger cohort studies are needed to further assess the potential benefit of MHAR in adult LDLT. From our experience, MHAR requires cooperation between the transplant and microsurgical teams, with technical challenges overcome with appropriate instrumentation and planning.
Collapse
Affiliation(s)
- Samantha Huang
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Artur Fahradyan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Aaron Ahearn
- Division of Hepatobiliary and Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Navpreet Kaur
- Division of Hepatobiliary and Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Linda Sher
- Division of Hepatobiliary and Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Yuri Genyk
- Division of Hepatobiliary and Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Juliet Emamaullee
- Division of Hepatobiliary and Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Ketan Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Joseph N Carey
- Keck School of Medicine, University of Southern California, Los Angeles, California.,Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| |
Collapse
|
2
|
Escandón JM, Bustos VP, Santamaría E, Langstein HN, Ciudad P, Hernandez-Alejandro R, Moore RG, Leckenby JI, Manrique OJ. Evolution and Transformation of Uterine Transplantation: A Systematic Review of Surgical Techniques and Outcomes. J Reconstr Microsurg 2021; 38:429-440. [PMID: 34535036 DOI: 10.1055/s-0041-1735261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Uterine transplantation (UTx) is acknowledged to be on the second (2A) of five steps of development in accordance with the staging system for the evaluation of surgical innovations. Accordingly, we aimed to systematically review the available evidence of the surgical techniques and outcomes of UTx in terms of graft survival. METHODS A comprehensive search was conducted across PubMed Medline, Cochrane-EBMR, Scopus, Web of Science, and CENTRAL through November 2020. RESULTS Forty studies, reporting 64 recipients and 64 donors, satisfied inclusion criteria. The surgical time and the estimated blood loss were 515 minutes and 679 mL for graft procurement via laparotomy, 210 minutes and 100 mL for laparoscopic-assisted graft harvest, and 660 minutes and 173 mL for robotic-assisted procedures, respectively. Urinary tract infections (n = 8) and injury to the urinary system (n = 6) were the most common donor complications. Using the donor's internal iliac system, two arterial anastomoses were performed in all cases. Venous outflow was accomplished through the uterine veins (UVs) in 13 cases, a combination of the UVs and the ovarian/uteroovarian veins (OVs/UOVs) in 36 cases, and solely through the OVs/UOVs in 13 cases. Ischemia time was 161 and 258 minutes when using living donors (LD) and deceased donors (DD), respectively. Forty-eight uteri were successfully transplanted or fulfilled the purpose of transplantation, 41 from LDs and 7 from DDs. Twenty-five and four live childbirths from LDs and DDs have been reported, respectively. CONCLUSION UTx is still experimental. Further series are required to recommend specific surgical techniques that best yield a successful transplant and reduce complications for donors and recipients.
Collapse
Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Eric Santamaría
- Department of Plastic and Reconstructive Surgery, Hospital General Dr. Manuel Gea Gonzalez, National Cancer Institute, Mexico City, Mexico
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Roberto Hernandez-Alejandro
- Department of Surgery and Division of Abdominal Transplantation and Hepatobiliary Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Richard G Moore
- Department of Obstetrics and Gynecology, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Jonathan I Leckenby
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| |
Collapse
|
3
|
Ebner PJ, Bick KJ, Emamaullee J, Stanton EW, Gould DJ, Patel KM, Genyk Y, Sher L, Carey JN. Microscope-Assisted Arterial Anastomosis in Adult Living Donor Liver Transplantation: A Systematic Review and Meta-analysis of Outcomes. J Reconstr Microsurg 2021; 38:306-312. [PMID: 34428807 DOI: 10.1055/s-0041-1732349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) has expanded the availability of liver transplant but has been associated with early technical complications including the devastating complication of hepatic artery thrombosis (HAT), which has been reported to occur in 14% to 25% of LDLT using standard anastomotic techniques. Microvascular hepatic artery reconstruction (MHAR) has been implemented in an attempt to decrease rates of HAT. The purpose of this study was to review the available literature in LDLT, specifically related to MHAR to determine its impact on rates of posttransplant complications including HAT. METHODS A systematic review was conducted using PubMed/Medline and Web of Science. Case series and reviews describing reports of microscope-assisted hepatic artery anastomosis in adult patients were considered for meta-analysis of factors contributing to HAT. RESULTS In all, 462 abstracts were screened, resulting in 20 studies that were included in the meta-analysis. This analysis included 2,457 patients from eight countries. The pooled rate of HAT was 2.20% with an overall effect size of 0.00906. CONCLUSION Systematic literature review suggests that MHAR during LDLT reduces vascular complications and improves outcomes posttransplant. Microvascular surgeons and transplant surgeons should collaborate when technical challenges such as small vessel size, short donor pedicle, or dissection of the recipient vessel wall are present.
Collapse
Affiliation(s)
- Peggy J Ebner
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Katherine J Bick
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Juliet Emamaullee
- Keck School of Medicine, University of Southern California, Los Angeles, California.,Division of Hepatobiliary and Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Eloise W Stanton
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Daniel J Gould
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Yuri Genyk
- Keck School of Medicine, University of Southern California, Los Angeles, California.,Division of Hepatobiliary and Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Linda Sher
- Keck School of Medicine, University of Southern California, Los Angeles, California.,Division of Hepatobiliary and Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
| |
Collapse
|
4
|
Dissemination and Implementation Science in Plastic and Reconstructive Surgery: Perfecting, Protecting, and Promoting the Innovation That Defines Our Specialty. Plast Reconstr Surg 2021; 147:303e-313e. [PMID: 33009331 DOI: 10.1097/prs.0000000000007492] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
SUMMARY Plastic and reconstructive surgery has an illustrious history of innovation. The advancement, if not the survival, of the specialty depends on the continual development and improvement of procedures, practices, and technologies. It follows that the safe adoption of innovation into clinical practice is also paramount. Traditionally, adoption has relied on the diffusion of new knowledge, which is a consistent but slow and passive process. The emerging field of dissemination and implementation science promises to expedite the spread and adoption of evidence-based interventions into clinical practice. The field is increasingly recognized as an important function of academia and is a growing priority for major health-related funding institutions. The authors discuss the contemporary challenges of the safe implementation and dissemination of new innovations in plastic and reconstructive surgery, and call on their colleagues to engage in this growing field of dissemination and implementation science.
Collapse
|