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Barron JO, Radhakrishnan K, Coppa C, Goldman D, Hupertz V, Leonis M, Eghtesad B, Hashimoto K. Ten-year follow-up of cavoportal hemitransposition in pediatric liver transplantation for complete portomesenteric venous thrombosis: A case report and literature review. Pediatr Transplant 2024; 28:e14738. [PMID: 38436520 DOI: 10.1111/petr.14738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/13/2023] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Portal vein thrombosis is a potentially devastating complication following pediatric liver transplantation. In rare instances of complete portomesenteric thrombosis, cavoportal hemitransposition may provide graft inflow. Here we describe long-term results following a case of pediatric cavoportal hemitransposition during liver transplantation and review the current pediatric literature. METHODS A 9-month-old female with a history of biliary atresia and failed Kasai portoenterostomy underwent living donor liver transplantation, which was complicated by portomesenteric venous thrombosis. The patient underwent retransplantation with cavoportal hemitransposition on postoperative day 12. OUTCOME The patient recovered without further complication, and 10 years later, she continues to do well, with normal graft function and no clinical sequelae of portal hypertension. CT scan with 3-D vascular reconstruction demonstrated recanalization of the splanchnic system, with systemic drainage to the inferior vena cava via an inferior mesenteric vein shunt. The cavoportal anastomosis remains patent with hepatopetal flow. Of the 12 previously reported cases of pediatric cavoportal hemitransposition as portal inflow in liver transplantation, this is the longest-known follow-up with a viable allograft. Notably, sequelae of portal hypertension were also rare in the 12 previously reported cases, with no cases of long-term renal dysfunction, lower extremity edema, or ascites. CONCLUSIONS Long-term survival beyond 10 years with normal graft function is feasible following pediatric cavoportal hemitransposition. Complications related to portal hypertension were generally short-lived, likely due to the development of robust collateral circulation. Additional reports of long-term outcomes are necessary to facilitate informed decision making when considering pediatric cavoportal hemitransposition for liver graft inflow.
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Affiliation(s)
- John O Barron
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kadakkal Radhakrishnan
- Department of Pediatric Hepatology and Gastroenterology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher Coppa
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deborah Goldman
- Department of Pediatric Hepatology and Gastroenterology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vera Hupertz
- Department of Pediatric Hepatology and Gastroenterology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mike Leonis
- Department of Pediatric Hepatology and Gastroenterology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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de Santibanes M, Ardiles V, Uño JW, Mattera J, de Santibanes E, Pekolj J. Surgical strategies to treat portal vein thrombosis during adult liver transplantation. Langenbecks Arch Surg 2023; 408:399. [PMID: 37831179 DOI: 10.1007/s00423-023-03141-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/04/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND The incidence of portal vein thrombosis (PVT) at the time of liver transplantation (LT) may be variable and underestimated. Therefore, preoperative diagnosis and stratification of its extension is so relevant for adequate surgical planning. Revascularization of the portal vein graft becomes essential for graft and patient survival after LT. Early stages of PVT may be managed with eversion thrombectomy and end-to-end anastomoses. However, severe PVT (grades 3 and 4) poses significant challenges for patients requiring LT, resulting in more complex surgeries and higher complication rates. To address these complexities, various surgical techniques have been developed, including collateral alternative vessel utilization, renoportal anastomoses, mesoportal jump graft placement, cavoportal hemitranspositions, portal vein arterialization, or even multivisceral transplantation. PURPOSE We herein describe the preoperative surgical planning as well as the different surgical strategies possible to treat portal vein thrombosis during LT. CONCLUSION A comprehensive preoperative evaluation of PVT is crucial for accurately assessing its extent and severity. This information is vital for proper surgical planning, which ultimately prepares both the surgeon and the patient for potentially complex procedures during LT. The surgical alternatives presented in this technical report offer promising solutions for treating PVT during LT, making it a viable option for selected patients.
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Affiliation(s)
- Martin de Santibanes
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina.
| | - Victoria Ardiles
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina
| | - Jimmy Walker Uño
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina
| | - Juan Mattera
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina
| | - Eduardo de Santibanes
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina
| | - Juan Pekolj
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina
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Kim SH, Moon DB, Kang WH, Jung DH, Lee SG. A surgical technique using the gastroepiploic vein for portal inflow restoration in living donor liver transplantation in a patient with diffuse portomesenteric thrombosis. Hepatobiliary Pancreat Dis Int 2023; 22:537-540. [PMID: 37005146 DOI: 10.1016/j.hbpd.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 03/16/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Sang-Hoon Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
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4
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Özbilgin M, Egeli T, Ağalar C, Özkardeşler S, Oğuz VA, Akarsu M, Sağol Ö, Ünek T, Karademir S, Astarcıoğlu I. Complications and Long-Term Outcomes in Adult Patients Undergoing Living Donor Liver Transplantation Because of Fulminant Hepatitis. Transplant Proc 2023:S0041-1345(23)00168-9. [PMID: 37137763 DOI: 10.1016/j.transproceed.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/05/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND The present study investigates the complications that may occur during long-term follow-up in patients aged 18 years and older undergoing living donor liver transplantation (LDLT) in our clinic because of fulminant hepatitis. METHODS The study included patients aged 18 years and older with a minimum survival of 6 months who underwent an LDLT between June 2000 and June 2017. The demographic data of the patients were evaluated in terms of late-term complications. RESULTS Of the 240 patients who met the study criteria, 8 (3.3%) underwent LDLT for fulminant hepatitis. The indication for transplantation in patients with fulminant hepatitis was cryptogenic liver hepatitis in 4 patients, acute hepatitis B infection in 2 patients, hemochromatosis in 1 patient, and toxic hepatitis in 1 patient. Of the 240 patients, 65 (27%) undergoing LDLT underwent a liver biopsy for suspected rejection because of an elevation in liver function test results during follow-up. Histopathologic scoring was carried out according to the Banff scoring system. A diagnosis of late acute rejection was made in only 1 of the 8 patients (12.5%) who underwent LDLT for fulminant hepatitis. CONCLUSION Patients with fulminant hepatitis must be prepared for an LDLT, if available, while waiting for a cadaveric donor. The results of the present study suggest that LDLTs in patients with fulminant hepatitis are safe, and the outcomes are acceptable in terms of survival and complications.
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Affiliation(s)
- Mücahit Özbilgin
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey.
| | - Tufan Egeli
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey
| | - Cihan Ağalar
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey
| | - Sevda Özkardeşler
- Department of Anesthesiology and Reanimation, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Vildan Avkan Oğuz
- Department of Infectious Diseases, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Mesut Akarsu
- Department of Gastroenterology, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Özgül Sağol
- Department of Pathology, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Tarkan Ünek
- Department of General Surgery, Dokuz Eylül University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit, Izmir, Turkey
| | - Sedat Karademir
- Department of General Surgery, Güven Hospital, Ankara, Turkey
| | - Ibrahim Astarcıoğlu
- Department of General Surgery, Memorial Bahçelievler Hospital, Istanbul, Turkey
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5
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Fundora Y, Hessheimer AJ, Del Prete L, Maroni L, Lanari J, Barrios O, Clarysse M, Gastaca M, Barrera Gómez M, Bonadona A, Janek J, Boscà A, Álamo Martínez JM, Zozaya G, López Garnica D, Magistri P, León F, Magini G, Patrono D, Ničovský J, Hakeem AR, Nadalin S, McCormack L, Palacios P, Zieniewicz K, Blanco G, Nuño J, Pérez Saborido B, Echeverri J, Bynon JS, Martins PN, López López V, Dayangac M, Lodge JPA, Romagnoli R, Toso C, Santoyo J, Di Benedetto F, Gómez-Gavara C, Rotellar F, Gómez-Bravo MÁ, López Andújar R, Girard E, Valdivieso A, Pirenne J, Lladó L, Germani G, Cescon M, Hashimoto K, Quintini C, Cillo U, Polak WG, Fondevila C. Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis. J Hepatol 2023; 78:794-804. [PMID: 36690281 DOI: 10.1016/j.jhep.2023.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND & AIMS Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. METHODS An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. RESULTS A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001). CONCLUSIONS Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. IMPACT AND IMPLICATIONS Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.
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Affiliation(s)
- Yiliam Fundora
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain
| | - Amelia J Hessheimer
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain; General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Luca Del Prete
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lorenzo Maroni
- Hepatobiliary Surgery & Transplant Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, Italy
| | - Jacopo Lanari
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Oriana Barrios
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Mikel Gastaca
- Hepatobiliary Surgery & Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain
| | - Manuel Barrera Gómez
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Agnès Bonadona
- Grenoble Alpes University, CHU Grenoble Alpes, Digestive Surgery & Liver Transplantation, Grenoble, France
| | - Julius Janek
- Department of Transplant Surgery, F.D. Roosevelt Hospital, Banská Bystrica, Slovakia
| | - Andrea Boscà
- Liver Transplantation & Hepatology Laboratory, Hepatology, HPB Surgery & Transplant Unit, Health Research Institute Hospital La Fe, La Fe University Hospital, Valencia, Spain
| | | | - Gabriel Zozaya
- HPB and Liver Transplant Unit, Clínica Universidad de Navarra; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | | | - Paolo Magistri
- Hepato-pancreato-biliary Surgery & Liver Transplantation Unit, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Francisco León
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Giulia Magini
- Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Damiano Patrono
- General Surgery 2U - Liver Transplant Centre, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Jiří Ničovský
- Centrum Kardiovaskulární a Transplantační Chirurgie, Brno, Czechia
| | - Abdul Rahman Hakeem
- Department of HPB and Liver Transplant Surgery, St. James's University Hospital, Leeds, UK
| | - Silvio Nadalin
- University of Tübingen, Tübingen, Germany; European Liver and Intestine Transplant Association (ELITA) Board
| | | | - Pilar Palacios
- Hospital Clínico Universitario de Zaragoza, Zaragoza, Spain
| | - Krzysztof Zieniewicz
- Medical University of Warsaw, Warsaw, Poland; European Liver and Intestine Transplant Association (ELITA) Board
| | - Gerardo Blanco
- Hospital Universitario de Badajoz, Universidad de Extremadura, Badajoz, Spain
| | - Javier Nuño
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Baltasar Pérez Saborido
- Hepatobiliopancreatic Surgery & Liver Transplant Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Juan Echeverri
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - J Steve Bynon
- University of Texas Houston - Memorial Hermann TMC, Houston, Texas, USA
| | - Paulo N Martins
- University of Massachusetts - Memorial Medical Center, Worcester, Massachusetts, USA
| | - Víctor López López
- Department of Surgery & Transplantation, Hospital Clínico Universitario Virgen de la Arrixaca, Murcian Institue of Biosanitary Research (IMIB), Murcia, Spain
| | - Murat Dayangac
- Medipol University Hospital Center for Organ Transplantation, Istanbul, Turkey
| | - J Peter A Lodge
- Department of HPB and Liver Transplant Surgery, St. James's University Hospital, Leeds, UK
| | - Renato Romagnoli
- General Surgery 2U - Liver Transplant Centre, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Christian Toso
- Hôpitaux Universitaires de Genève, Geneva, Switzerland; European Liver and Intestine Transplant Association (ELITA) Board
| | - Julio Santoyo
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Fabrizio Di Benedetto
- Hepato-pancreato-biliary Surgery & Liver Transplantation Unit, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | | | - Fernando Rotellar
- HPB and Liver Transplant Unit, Clínica Universidad de Navarra; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | | | - Rafael López Andújar
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain; Liver Transplantation & Hepatology Laboratory, Hepatology, HPB Surgery & Transplant Unit, Health Research Institute Hospital La Fe, La Fe University Hospital, Valencia, Spain
| | - Edouard Girard
- Grenoble Alpes University, CHU Grenoble Alpes, Digestive Surgery & Liver Transplantation, Grenoble, France
| | - Andrés Valdivieso
- Hepatobiliary Surgery & Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain
| | - Jacques Pirenne
- Abdominal Transplant Surgery, UZ Leuven, KUL, Leuven, Belgium
| | - Laura Lladó
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Giacomo Germani
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy; European Liver and Intestine Transplant Association (ELITA) Board
| | - Matteo Cescon
- Hepatobiliary Surgery & Transplant Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, Italy
| | - Koji Hashimoto
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cristiano Quintini
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Umberto Cillo
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Wojciech G Polak
- Division of HPB & Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands; European Liver and Intestine Transplant Association (ELITA) Board
| | - Constantino Fondevila
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain; General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain; European Liver and Intestine Transplant Association (ELITA) Board.
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Pinelli D, Cescon M, Ravaioli M, Neri F, Amaduzzi A, Serenari M, Carioli G, Siniscalchi A, Colledan M. Liver Transplantation in Patients with Portal Vein Thrombosis: Revisiting Outcomes According to Surgical Techniques. J Clin Med 2023; 12:jcm12072457. [PMID: 37048541 PMCID: PMC10095520 DOI: 10.3390/jcm12072457] [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: 02/13/2023] [Revised: 03/10/2023] [Accepted: 03/14/2023] [Indexed: 04/14/2023] Open
Abstract
Surgical strategies for graft portal vein flow restoration vary from termino-terminal portal vein anastomosis to more complex bypass reconstructions. Although the surgical strategy strongly influences the post-operative outcome, the Yerdel grading is still commonly used to determine the prognosis of patients with portal vein thrombosis (PVT) undergoing liver transplantation (LT). We retrospectively reviewed the cases of LT performed on recipients with complex PVT at two high-volume transplantation centres. We stratified the patients by the type of portal vein reconstruction, termino-terminal portal vein anastomosis (TTA) versus bypass reconstruction (bypass group), and assessed a multivariable survival analysis. The rate of mortality at 90 days was 21.4% for the bypass group compared to 9.8% in the TTA group (p = 0.05). In the multivariable correlation analysis, only a trend for greater risk of early mortality was confirmed in the bypass groups (HR 2.5; p = 0.059). Yerdel grade was uninfluential in the rate of early complications. A wide range of surgical options are available for different situations of PVT which yield an outcome unrelated to the Yerdel grading. An algorithm for PVT management should be based on the technical approach and should include a surgically oriented definition of PVT extension.
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Affiliation(s)
- Domenico Pinelli
- Department of Organ Failure and Transplantation, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Matteo Cescon
- Hepatobiliary and Transplant Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, 40138 Bologna, Italy
| | - Matteo Ravaioli
- Hepatobiliary and Transplant Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, 40138 Bologna, Italy
| | - Flavia Neri
- Department of Organ Failure and Transplantation, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Annalisa Amaduzzi
- Department of Organ Failure and Transplantation, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Matteo Serenari
- Hepatobiliary and Transplant Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, 40138 Bologna, Italy
| | - Greta Carioli
- FROM Research Foundation, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Antonio Siniscalchi
- Anesthesia and Intensive Care Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, 40138 Bologna, Italy
| | - Michele Colledan
- Department of Organ Failure and Transplantation, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy
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7
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Talwar A, Varghese J, Knight GM, Katariya N, Caicedo JC, Dietch Z, Borja-Cacho D, Ladner D, Christopher D, Baker T, Abecassis M, Mouli S, Desai K, Riaz A, Thornburg B, Salem R. Preoperative portal vein recanalization-transjugular intrahepatic portosystemic shunt for chronic obliterative portal vein thrombosis: Outcomes following liver transplantation. Hepatol Commun 2022; 6:1803-1812. [PMID: 35220693 PMCID: PMC9234680 DOI: 10.1002/hep4.1914] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 12/16/2021] [Accepted: 01/08/2022] [Indexed: 11/09/2022] Open
Abstract
High-grade portal vein thrombosis (PVT) is often considered to be a technically challenging scenario for liver transplantation (LT) and in some centers a relative contraindication. This study compares patients with chronic obliterative PVT who underwent portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) and subsequent LT to those with partial nonocclusive PVT who underwent LT without an intervention. This institutional review board-approved study analyzed 49 patients with cirrhosis with PVT from 2000 to 2020 at our institution. Patients were divided into two groups, those that received PVR-TIPS due to anticipated surgical challenges from chronic obliterative PVT and those who did not because of partial PVT. Demographic data and long-term outcomes were compared. A total of 35 patients received PVR-TIPS while 14 did not, with all receiving LT. Patients with PVR-TIPS had a higher Yerdel score and frequency of cavernoma than those that did not. PVR-TIPS was effective in decreasing portosystemic gradient (16 down to 8 mm HG; p < 0.05). Both groups allowed for end-to-end anastomoses in >90% of cases. However, veno-veno bypass was used significantly more in patients who did not receive PVR-TIPS. Additionally, patients without PVR-TIPS required significantly more intraoperative red blood cells. Overall survival was not different between groups. PVR-TIPS demonstrated efficacy in resolving PVT and allowed for end-to-end portal vein anastomoses. PVR-TIPS is a viable treatment option for chronic obliterative PVT with or without cavernoma that simplifies the surgical aspects of LT.
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Affiliation(s)
- Abhinav Talwar
- Department of RadiologySection of Vascular and Interventional RadiologyNorthwestern UniversityChicagoIllinoisUSA
| | - Jeffrey Varghese
- Department of RadiologySection of Vascular and Interventional RadiologyNorthwestern UniversityChicagoIllinoisUSA
| | - Gabriel M Knight
- Department of RadiologySection of Vascular and Interventional RadiologyNorthwestern UniversityChicagoIllinoisUSA
| | - Nitin Katariya
- Department of SurgeryDivision of Transplant SurgeryNorthwestern UniversityChicagoIllinoisUSA
| | - Juan-Carlos Caicedo
- Department of SurgeryDivision of Transplant SurgeryNorthwestern UniversityChicagoIllinoisUSA
| | - Zach Dietch
- Department of SurgeryDivision of Transplant SurgeryNorthwestern UniversityChicagoIllinoisUSA
| | - Daniel Borja-Cacho
- Department of SurgeryDivision of Transplant SurgeryNorthwestern UniversityChicagoIllinoisUSA
| | - Daniella Ladner
- Department of SurgeryDivision of Transplant SurgeryNorthwestern UniversityChicagoIllinoisUSA
| | - Derrick Christopher
- Department of SurgeryDivision of Transplant SurgeryNorthwestern UniversityChicagoIllinoisUSA
| | - Talia Baker
- Department of SurgeryDivision of Transplant SurgeryUniversity of ChicagoChicagoIllinoisUSA
| | - Michael Abecassis
- Department of SurgeryDivision of Transplant SurgeryUniversity of ArizonaTucsonArizonaUSA
| | - Samdeep Mouli
- Department of RadiologySection of Vascular and Interventional RadiologyNorthwestern UniversityChicagoIllinoisUSA
| | - Kush Desai
- Department of RadiologySection of Vascular and Interventional RadiologyNorthwestern UniversityChicagoIllinoisUSA
| | - Ahsun Riaz
- Department of RadiologySection of Vascular and Interventional RadiologyNorthwestern UniversityChicagoIllinoisUSA
| | - Bart Thornburg
- Department of RadiologySection of Vascular and Interventional RadiologyNorthwestern UniversityChicagoIllinoisUSA
| | - Riad Salem
- Department of RadiologySection of Vascular and Interventional RadiologyNorthwestern UniversityChicagoIllinoisUSA
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8
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Pinelli D, Neri F, Tornese S, Amaduzzi A, Camagni S, D'Antiga L, Fagiuoli S, Colledan M. Physiological reno-portal bypass in liver transplantation with non-tumorous portal vein thrombosis. Updates Surg 2022; 74:1617-1626. [PMID: 35441945 DOI: 10.1007/s13304-022-01280-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 03/11/2022] [Indexed: 11/25/2022]
Abstract
Reno-portal anastomosis (RPA) in presence of spleno-renal shunts (SRS) is a physiological option to restore blood flow in liver transplantation with portal vein thrombosis (PVT). Diffuse splanchnic venous system thrombosis (complex PVT) is its main indication but RPA proved to be useful in selected cases of less extensive thrombosis (non-complex PVT). Up until now only two monocentric and one multicentric case series has been published on this topic in addition to few anecdotal reports. After 2014, we introduced RPA in our institution to manage some cases of complex PVT in presence of SRS. Here, we present the evolution of indication to RPA. From 2014 to 2020, we performed ten RPA: nine patients presented non-complex and one complex PVT. Overall early and late complication rates were 66.6% and 50%, respectively. Two patients developed RPA stenosis, treated by interventional radiology. Self-resolving acute kidney injury (AKI) was observed in three cases. No re-transplantation was necessary. RPA was patent in all patients, with a mean follow-up of 41.9 months. The overall patient survival was 70% at 1 year and 60% at 3 and 5 years. Four patients died at 1, 2, 3 and 20 months from LT. Causes of deaths were, respectively, stroke, cerebral infection, sepsis (MOF) and sudden variceal bleeding in sinusoidal obstruction syndrome. The relative simplicity and effectiveness of RPA in presence of SRS allowed us to rely more and more often on this technique in liver transplantation with challenging non-complex PVT.
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Affiliation(s)
- Domenico Pinelli
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy.
| | - Flavia Neri
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Stefania Tornese
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Annalisa Amaduzzi
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Stefania Camagni
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Stefano Fagiuoli
- Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Michele Colledan
- General Surgery, Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
- Università di Milano - Bicocca, Piazza dell'Ateneo Nuovo, 1, 20126, Milano, MI, Italy
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9
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Clarysse M, Wilmer A, Debaveye Y, Laleman W, Devos T, Canovai E, Verslype C, van der Merwe S, van Malenstein H, Nevens F, Maleux G, Sainz-Barriga M, Monbaliu D, Pirenne J. Recanalization of portal axis after cavoportal hemitransposition in a liver transplant recipient with complete splanchnic thrombosis. Pediatr Transplant 2021; 25:e14097. [PMID: 34289227 DOI: 10.1111/petr.14097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Diffuse splanchnic thrombosis may render standard LTx difficult or even technically impossible. A 19-year-old woman with acute-on-chronic Budd-Chiari syndrome and complete splanchnic thrombosis underwent conventional LTx. Only limited anatomical portal inflow could be restored, and urgent re-transplantation for recurrent splanchnic vein thrombosis became necessary. METHODS At re-transplant, and in addition to the reestablishment of some portal inflow through the preserved original porto (native)-portal (graft) connection, a cavoportal shunt was created (first partial via 30% tapering of the vena cava, but eventually complete by total occlusion of the vena cava). RESULTS The postoperative course was then uneventful, and interestingly, the native portomesenteric axis gradually reopened. Two years post-transplant, the liver graft is perfused via both physiological and non-physiological sources. Liver function is normal. There is no IVC syndrome and no residual PHT. She is leading a normal life. CONCLUSION Creation of CPHT, in addition to the preservation of portal inflow from the native splanchnic system, should be considered in patients with diffuse splanchnic thrombosis, when sufficient physiological portal inflow cannot be restored at the time of LTx, but in whom the splanchnic circulation may reopen up later.
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Affiliation(s)
- Mathias Clarysse
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Alexander Wilmer
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium.,Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Yves Debaveye
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Hepatology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Timothy Devos
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Molecular Immunology (Rega Institute), Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Emilio Canovai
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Chris Verslype
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Clinical Digestive Oncology, Department of Digestive Oncology, KU Leuven, Leuven, Belgium
| | - Schalk van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Hepatology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Hannah van Malenstein
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Hepatology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Hepatology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, Section of Interventional Radiology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Radiology, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Mauricio Sainz-Barriga
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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10
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Kotsifa E, Kykalos S, Machairas N, Nikiteas N, Sotiropoulos GC. Management of portal vein thrombosis in cirrhotic patients enlisted for liver transplantation: From diagnosis to treatment (Review). Biomed Rep 2021; 15:94. [PMID: 34631049 DOI: 10.3892/br.2021.1470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 07/28/2021] [Indexed: 12/11/2022] Open
Abstract
Portal vein thrombosis (PVT) commonly occurs in patients with cirrhosis. Several classification systems of PVT have been proposed over the years reflecting the challenge in establishing a widely accepted system. To date, PVT has been considered an absolute contraindication for orthotopic liver transplantation (OLT) since it is associated with decreased graft survival and increased patient mortality. Nevertheless, the development of modern surgical techniques has enabled the inclusion of these candidates in OLT waiting lists, since their postoperative results are shown to be comparable to those of patients without PVT. The aim of the present review was to critically appraise the available treatment options for cirrhotic patients enlisted for liver transplantation in the setting of PVT.
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Affiliation(s)
- Evgenia Kotsifa
- Second Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Stylianos Kykalos
- Second Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos Machairas
- Second Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos Nikiteas
- Second Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Georgios C Sotiropoulos
- Second Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
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11
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Kubo M, Gotoh K, Kobayashi S, Iwagami Y, Yamada D, Tomimaru Y, Akita H, Noda T, Marubashi S, Nagano H, Dono K, Doki Y, Eguchi H. Modified Cavoportal Hemitransposition for Severe Portal Vein Thrombosis Contributed to Long-term Survival After Deceased Donor Liver Transplantation-Insight Into Portal Modulation for Improving Survival: A Case Report. Transplant Proc 2021; 53:2580-2587. [PMID: 34253382 DOI: 10.1016/j.transproceed.2021.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/25/2021] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Severe/massive portal vein thrombosis (PVT) deteriorates peri-liver transplantation outcomes. Cavoportal hemitransposition (CPHT) is a rescue procedure for severe PVT, and short-term outcomes have been well studied. However, CPHT is associated with some long-term issues caused by portal flow modulation via extraordinary reconstruction. We describe a patient with Yerdel grade 4 PVT who underwent a liver transplant and achieved long-term survival with CPHT and a portosystemic shunt. CASE REPORT A 50-year-old man with liver cirrhosis underwent a deceased donor liver transplant. Preoperative examinations indicated Yerdel grade 4 PVT; thus, we planned a CPHT. In liver transplant surgery, we confirmed diffusely complete PVT and removed them as possible. After placing a liver graft, we performed CPHT and confirmed that the graft received sufficient portal vein flow. However, the gastroepiploic vein pressure increased significantly. Therefore, we added a portosystemic shunt between the splenic vein and the inferior vena cava, and the pressure improved. The patient was discharged after an uneventful hospital stay, and he reported no unfavorable events for over 12 years. CONCLUSIONS This case study suggested that a modified CPHT with a portosystemic shunt for Grade 4 PVT was useful in preventing post-liver transplant PVT development and improved the outcome.
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Affiliation(s)
- Masahiko Kubo
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shigeru Marubashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hiroaki Nagano
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Keizo Dono
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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12
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D'Amico G, Matsushima H, Del Prete L, Diago Uso T, Armanyous SR, Hashimoto K, Eghtesad B, Fujiki M, Aucejo F, Sasaki K, Kwon CHD, Simioni A, Miller C, Quintini C. Long term outcomes and complications of reno-portal anastomosis in liver transplantation: results from a propensity score-based outcome analysis. Transpl Int 2021; 34:1938-1947. [PMID: 34008257 DOI: 10.1111/tri.13920] [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] [Received: 01/14/2021] [Revised: 04/29/2021] [Accepted: 05/11/2021] [Indexed: 12/23/2022]
Abstract
Diffuse splanchnic vein thrombosis (DSVT) remains a serious challenge in liver transplantation (LT). Reno-portal anastomosis (RPA) has previously been reported as a valid option for management of patients with DSVT during LT. The aim of this study was to evaluate post-transplant renal function and surgical outcomes of patients with DSVT who underwent RPA during LT. Between January 2005 and December 2017, 1270 patients underwent LT at our institution, including 16 with DSVT managed with RPA (RPA group). We compared renal function and surgical outcomes in these patients to outcomes in 48 propensity score (PS)-matched patients without thrombosis (control group), using a 1:3 matching model. The two groups had similar rates of postoperative portal vein thrombosis (PVT), renal dysfunction as measured by estimated glomerular filtration rate (eGFR), and overall postoperative complications (Clavien grade III), although the RPA group had a higher incidence of postoperative upper gastrointestinal (GI) bleeding (31.3% vs 4.2%; P = 0.009) that had no clinical consequence. There were no significant differences in five-year graft and patient survival rates between the groups (P = 0.133 and P = 0.166, respectively). RPA is an established technique in the management of patients with DSVT during LT, with comparable outcomes to patients without thrombosis. Our report is the first to demonstrate similar surgical outcomes, including long-term renal function, in LT recipients with or without RPA.
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Affiliation(s)
| | | | - Luca Del Prete
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Bijan Eghtesad
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Federico Aucejo
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Kazunari Sasaki
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | | | - Andrea Simioni
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
| | - Charles Miller
- Transplantation Center, Cleveland Clinic, Cleveland, OH, USA
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13
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Liou P, Kato T, Fishbein T. Surgical Perspectives on the American Association for the Study of Liver Diseases Guideline for Anticoagulation and Implications for Liver Transplantation. Liver Transpl 2021; 27:580-583. [PMID: 37160043 DOI: 10.1002/lt.25990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Peter Liou
- Center for Liver Disease and Transplantation, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Tomoaki Kato
- Center for Liver Disease and Transplantation, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Thomas Fishbein
- Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
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14
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Cubisino A, Navarro F, Panaro F. Cavoportal Transposition for the Management of Extensive Portal System Thrombosis During Liver Transplantation. Prog Transplant 2021; 31:193-194. [PMID: 33722104 DOI: 10.1177/15269248211002812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Antonio Cubisino
- Division of HBP Surgery and Transplantation, Department of Surgery, Hôpital Saint Eloi, 26905CHU-Montpellier, Montpellier, France
| | - Francis Navarro
- Division of HBP Surgery and Transplantation, Department of Surgery, Hôpital Saint Eloi, 26905CHU-Montpellier, Montpellier, France
| | - Fabrizio Panaro
- Division of HBP Surgery and Transplantation, Department of Surgery, Hôpital Saint Eloi, 26905CHU-Montpellier, Montpellier, France
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15
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Tekin A, Beduschi T, Vianna R, Mangus RS. Multivisceral transplant as an option to transplant cirrhotic patients with severe portal vein thrombosis. Int J Surg 2020; 82S:115-121. [PMID: 32739540 DOI: 10.1016/j.ijsu.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/15/2022]
Abstract
Non-tumoral portal vein thrombosis (PVT) is a critical complication in the patient with advanced cirrhosis awaiting liver transplantation (LT). With the evolution of liver transplant (LT) technique, PVT has morphed from an absolute contraindication to a relative contraindication, depending on the grade of the thrombus. The Yerdel classification is one system of grading PVT severity. Patients with Yerdel class 1-3 PVT can undergo LT at centers with experience in complex portal vein (PV) dissection, thrombectomy, and reconstruction. Class 4 PVT, however, is even more complex and may require heroic techniques such as cavoportal hemitransposition, PV arterialization or multivisceral transplant (MVT). Some centers use a MVT back-up approach for patients with Yerdel class 4 PVT. In these patients, all organs with PV outflow are procured simultaneously as a cluster graft from a deceased donor (liver, pancreas, intestine±stomach). If physiologic PV inflow is established intraoperatively, the recipient undergoes LT. Otherwise the MVT graft is transplanted. MVT establishes physiologic PV flow, but transplantation of the intestine confers significant lifelong risks including rejection, graft-versus host disease and post-transplant lymphoma. Yerdel class 1-4 PVT patients undergoing successful LT have 5-year survival similar to non-PVT patients, while patients requiring full MVT experience somewhat higher mortality because of the complexity of the surgery and medical management.
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16
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Lee JM, Lee KW. Techniques for overcoming atretic changes of the portal vein in living donor liver transplantation. Hepatobiliary Pancreat Dis Int 2020; 19:311-317. [PMID: 32636060 DOI: 10.1016/j.hbpd.2020.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/23/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Spontaneous diversion of the portal flow through collateral vessels into the systemic circulation is frequently observed in liver transplant recipients with severe portal hypertension. This induces main portal vein atretic change and modifies flow into the collateral even after donor graft implantation. These atretic changes make liver transplantation challenging. In this article we described several methods for overcoming this challenge by appropriate surgical techniques. METHODS Three anastomotic techniques for living donor liver transplantation were performed in patients with atretic changes in the portal vein. RESULTS The three techniques were (1) venoplasty to widen the diameter by using the recipient's portal vein, and the diameter of the recipient's portal vein was enlarged using their own portal vein stump patch; (2) conduit with cryopreserved vessels, and we dissected around the superior mesenteric vein and splenic vein junction and a conduit was built using the cryopreserved vessels; and (3) left gastric varix to portal vein anastomosis, if the recipients had large gastric varix and variceal wall was sufficiently thick for anastomosis. CONCLUSIONS Selection of optimal methods for portal vein anastomosis is essential in patients with atrophic change on the portal vein. If these methods are used aptly, they can be considered as favorable methods for overcoming each situation.
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Affiliation(s)
- Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea.
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17
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Intraoperative Challenge for Vascular Reconstruction in Orthotopic Liver Transplantation Because of Extensive Portal Thrombosis and Intimal Dissection of the Hepatic Artery. ACG Case Rep J 2020; 7:e00390. [PMID: 32656292 PMCID: PMC7319335 DOI: 10.14309/crj.0000000000000390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/10/2020] [Indexed: 11/17/2022] Open
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18
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Teng F, Sun KY, Fu ZR. Tailored classification of portal vein thrombosis for liver transplantation: Focus on strategies for portal vein inflow reconstruction. World J Gastroenterol 2020; 26:2691-2701. [PMID: 32550747 PMCID: PMC7284174 DOI: 10.3748/wjg.v26.i21.2691] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/25/2020] [Accepted: 04/21/2020] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is currently not considered a contraindication for liver transplantation (LT), but diffuse or complicated PVT remains a major surgical challenge. Here, we review the prevalence, natural course and current grading systems of PVT and propose a tailored classification of PVT in the setting of LT. PVT in liver transplant recipients is classified into three types, corresponding to three portal reconstruction strategies: Anatomical, physiological and non-physiological. Type I PVT can be removed via low dissection of the portal vein (PV) or thrombectomy; porto-portal anastomosis is then performed with or without an interposed vascular graft. Physiological reconstruction used for type II PVT includes vascular interposition between mesenteric veins and PV, collateral-PV and splenic vein-PV anastomosis. Non-physiological reconstruction used for type III PVT includes cavoportal hemitransposition, renoportal anastomosis, portal vein arterialization and multivisceral transplantation. All portal reconstruction techniques were reviewed. This tailored classification system stratifies PVT patients by surgical complexity, risk of postoperative complications and long-term survival. We advocate using the tailored classification for PVT grading before LT, which will urge transplant surgeons to make a better preoperative planning and pay more attention to all potential strategies for portal reconstruction. Further verification in a large-sample cohort study is needed.
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Affiliation(s)
- Fei Teng
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
| | - Ke-Yan Sun
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
| | - Zhi-Ren Fu
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
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19
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Kuriyama N, Kazuaki G, Hayasaki A, Fujii T, Iizawa Y, Kato H, Murata Y, Tanemura A, Kishiwada M, Sakurai H, Isaji S, Mizuno S. Surgical Procedures of Portal Vein Reconstruction for Recipients With Portal Vein Thrombosis in Adult-to-Adult Living Donor Liver Transplantation. Transplant Proc 2020; 52:1802-1806. [PMID: 32448668 DOI: 10.1016/j.transproceed.2020.01.155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 01/22/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Portal vein (PV) reconstruction is an important surgical skill for living donor liver transplantation (LDLT), especially for patients with portal vein thrombosis (PVT). However, this technique remains a critical problem in LDLT because of technical demands and requirements for appropriate venous graft harvesting. This study aimed to evaluate the surgical procedure used for PV reconstruction and outcomes in LDLT recipients with PVT. METHODS Between March 2002 and December 2018, 128 adult LDLTs were performed. Fourteen recipients (10.8%) had PVT at the time of LDLT, classified as grade I in 2, grade II in 5, grade III in 6, and grade IV in 1, according to the Yerdel classification. We retrospectively analyzed the surgical procedure and postoperative complications associated with PV reconstruction of recipients with PVT. RESULTS Surgical treatments for 14 recipients with PVT were as follows: thrombectomies in 2 recipients, replacement of interpositional venous grafts using the internal jugular vein (IJV) in 3 recipients and the external iliac vein (EIV) in 6 recipients, mesoportal jump grafts using the IJV in 1 recipient and the IJV + EIV in 1 recipient, and renoportal anastomosis using the EIV in 1 recipient. Among interpositional venous grafts, 5 venous grafts (IJV: 2, EIV: 3) passed the dorsal side of the pancreas without using the jump graft. Postoperative complications associated with PV anastomosis occurred in 1 of 14 (7.1%) recipients, who developed anastomosis bleeding caused by coagulation disorders at 27 days after LDLT, without any strictures of PV anastomoses. The overall survival rate at 5 years posttransplant was not statistically different between recipients with and without PVT (50.0% vs 65.0%, P = .163). CONCLUSION Our techniques of PV reconstruction, using the appropriate venous grafts and route, are feasible, resulting in a prognosis comparable to that of recipients without PVT.
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Affiliation(s)
- Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan.
| | - Gyoten Kazuaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroyuki Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
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20
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Bhangui P, Fernandes ESM, Di Benedetto F, Joo DJ, Nadalin S. Current management of portal vein thrombosis in liver transplantation. Int J Surg 2020; 82S:122-127. [PMID: 32387201 DOI: 10.1016/j.ijsu.2020.04.068] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/15/2020] [Accepted: 04/28/2020] [Indexed: 02/07/2023]
Abstract
Nontumoral portal vein thrombosis (PVT) is present at liver transplantation (LT) in 5-26% of cirrhotic patients, and is known to affect post LT outcomes. Up to 31% of patients who are found to have PVT at the time of LT, would have had PVT at the time of initial listing, but others develop PVT during the waiting period. Adequate screening and treatment of the PVT on the waiting list for LT is thus essential so that a portoportal anastomoses can be performed at the time of LT. Early PVT (Yerdel Grade I/II) can be usually managed by thrombectomy, whereas Grade III PVT may require a jump graft from the superior mesenteric vein to the graft PV. Complete portomesenteric thrombosis is a huge challenge, and sometimes a cause for denying a LT in these patients, with multivisceral transplant being the only alternative. The presence of spontaneous, or previously surgically created portosytemic shunts like the leinorenal shunt, may serve as a good inflow option (renoportal anastomosis) in these patients to establish a physiological reconstruction. Although challenging, good outcomes are possible in patients with complex PVT if the appropriate surgical technique is chosen to ensure portal inflow and resolution of PHT post LT.
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Affiliation(s)
- Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi-NCR, India.
| | - Eduardo S M Fernandes
- Department of Gastrointestinal Surgery - Rio de Janeiro Federal University and Liver Transplant Unit - São Lucas Hospital RJ, Brazil
| | - Fabrizio Di Benedetto
- HPB Surgery and Liver Transplant Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Dong-Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Silvio Nadalin
- Department of General, Visceral and Transplantation Surgery, University Hospital Tuebingen, Tübingen, Germany
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21
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Puri Y, Gunasekaran V, Palanisamy SK, Elangovan B, Krishna P, Balasubramanian B, Ananth A, Reddy MS, Rela M. A Novel Technique of Physiological Portal Inflow Augmentation During Liver Transplantation for Yerdel Grade 4 Portal Vein Thrombosis. Liver Transpl 2020; 26:294-298. [PMID: 31724287 DOI: 10.1002/lt.25680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/29/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Yogesh Puri
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | | | - Shiva Kumar Palanisamy
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Babu Elangovan
- Department of Surgical Gastroenterology and Liver Transplant, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Pradeep Krishna
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Balaji Balasubramanian
- Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Anjana Ananth
- Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Mettu Srinivas Reddy
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Mohamed Rela
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
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22
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Lerut JP, Lai Q, de Ville de Goyet J. Cavoportal Hemitransposition in Liver Transplantation: Toward a More Safe and Efficient Technique. Liver Transpl 2020; 26:92-99. [PMID: 31509649 DOI: 10.1002/lt.25635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
Extended splanchnic venous thrombosis represents a challenge for the liver transplantation (LT) surgeon. In the absence of large venous tributaries, the cavoportal hemitransposition (CPHTr) and the combined liver-intestinal or multivisceral transplantation are the only technical solutions. Because of the reported high morbidity and mortality rates due to infrequent use and a lack of standardization, the former technique has been almost abandoned by the transplant community. A newly designed technique of CPHTr is presented that is based on the combination of an inferior vena cava (IVC)-sparing hepatectomy and large laterolateral cavocaval and end-to-side cavoportal anastomoses separated only by a double vascular stapler line. This technique allows the splanchnic blood to be completely diverted toward the allograft and to eliminate low-flow IVC areas, which possibly lead to complications. The modified CPHTr technique proposed here offers a valuable alternative to much more complex and invasive intestinal transplantation procedures.
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Affiliation(s)
- Jan P Lerut
- Institute for Experimental and Clinical Research, Université Catholique de Louvain, Brussels, Belgium
| | - Quirino Lai
- Liver Transplant Program, Sapienza University of Rome, Rome, Italy
| | - Jean de Ville de Goyet
- University Pittsburgh Medical Center-Italy, Istituto Mediterraneo for Trapianto e Terapie ad Alta Specializzazione, Istituto di Ricovero e Cura a Carattere Scientifico, Palermo, Italy
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23
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Bhangui P, Lim C, Levesque E, Salloum C, Lahat E, Feray C, Azoulay D. Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation. J Hepatol 2019; 71:1038-1050. [PMID: 31442476 DOI: 10.1016/j.jhep.2019.08.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/25/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023]
Abstract
Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.
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Affiliation(s)
- Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, New Delhi, India
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Paris, France
| | - Eric Levesque
- Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel
| | - Cyrille Feray
- Department of Hepatology, Paul Brousse Hospital, Villejuif, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France; Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel.
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24
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Sasaki K, McVey JC, Firl DJ, Andreatos N, Moro A, Coromina Hernandez L, Matsushima H, Teresa DU, Fujiki M, Aucejo FN, Quintini C, Kwon CD, Eghtesad B, Miller CM, Hashimoto K. Sufficient hepatic artery flow compensates for poor portal vein flow after liver transplantation in patients with portal vein thrombosis. Clin Transplant 2019; 33:e13723. [DOI: 10.1111/ctr.13723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/28/2019] [Accepted: 09/14/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Kazunari Sasaki
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - John C. McVey
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Daniel J. Firl
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | | | - Amika Moro
- Japanese National Physician Graduate Medical Education Program United States Naval Hospital Okinawa Okinawa Japan
| | - Laia Coromina Hernandez
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Hajime Matsushima
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Diago Uso Teresa
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Masato Fujiki
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Federico N. Aucejo
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Cristiano Quintini
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Choon‐Hyuck D. Kwon
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Bijan Eghtesad
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Charles M. Miller
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
| | - Koji Hashimoto
- Cleveland Clinic Lerner College of Medicine and Department of General Surgery Digestive Disease Institute Cleveland Clinic Cleveland Ohio
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25
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Soejima Y, Yoshizumi T, Ikegami T, Harimoto N, Harada N, Itoh S, Toshima T, Motomura T, Mano Y, Ohira M, Bekki Y, Maehara Y. Real-Time Ultrasound-Guided Thrombectomy for Extensive Portal Vein Thrombosis in Living Donor Liver Transplantation. Transplant Proc 2018; 50:3549-3551. [DOI: 10.1016/j.transproceed.2018.08.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/24/2018] [Accepted: 08/16/2018] [Indexed: 10/28/2022]
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26
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D'Amico G, Hassan A, Diago Uso T, Hashmimoto K, Aucejo FN, Fujiki M, Eghtesad B, Sasaki K, Lindenmeyer CC, Miller CM, Quintini C. Renoportal anastomosis in liver transplantation and its impact on patient outcomes: a systematic literature review. Transpl Int 2018; 32:117-127. [DOI: 10.1111/tri.13368] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 06/28/2018] [Accepted: 10/19/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Giuseppe D'Amico
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Ahmed Hassan
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Teresa Diago Uso
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Koji Hashmimoto
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Federico N. Aucejo
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Masato Fujiki
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Bijan Eghtesad
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Kazunari Sasaki
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Christina C. Lindenmeyer
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Charles M. Miller
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
| | - Cristiano Quintini
- Transplantation Center; Department of General Surgery, Digestive Disease and Surgery Institute; Cleveland Clinic; Cleveland OH USA
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27
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Grezzana-Filho TJM, Chedid MF, Chedid AD, Bassani-Filho EL, Pereira PF, Leipnitz I, Backes AN, Kruel CRP. How to do liver transplantation using renoportal bypass. ANZ J Surg 2017; 88:236-237. [PMID: 29216680 DOI: 10.1111/ans.14299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Tomaz J M Grezzana-Filho
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Marcio F Chedid
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Aljamir D Chedid
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Ernidio L Bassani-Filho
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Pedro F Pereira
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Ian Leipnitz
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Ariane N Backes
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Cleber R P Kruel
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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28
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Nazzal M, Sun Y, Okoye O, Diggs L, Evans N, Osborn T, Etesami K, Varma C. Reno-portal shunt for liver transplant, an alternative inflow for recipients with grade III-IV portal vein thrombosis: Tips for a better outcome. Int J Surg Case Rep 2017; 41:251-254. [PMID: 29102862 PMCID: PMC5742012 DOI: 10.1016/j.ijscr.2017.09.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Portal vein thrombosis (PVT) poses an extremely difficult problem in cirrhotic patients who are in need of a liver transplant. The prevalence of PVT in patients with cirrhosis ranges from 0.6% to 26% Nery et al. (2015) [1]. The presence of PVT is associated with more technically difficult liver transplant and in certain cases can be a contraindication to liver transplant. The only option for these patients with extensive PVT would be a multi-visceral transplant, the later unfortunately has a much higher morbidity and mortality compared to liver only transplant Smith et al. (2016) [2]. An alternative approach is needed to provide a safe and reliable outcome. PRESENTATION OF CASE In this case series, we present our experience with reno-portal shunt as an alternative inflow for the liver allograft. DISCUSSION This approach appears to be safe with good long-term outcome.Although this technique has been described before, we provide additional considerations that produced good outcomes in our patients. CONCLUSION We believe that meticulous preoperative planning with high-resolution triple phase CT imaging with a measurement of the diameter of the spleno-renal shunt along with a duplex scan measuring flow through the shunt is key to a successful transplantation. Moreover, appropriate donor liver size is also of extreme importance to avoid portal hypoperfusion.
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Affiliation(s)
- Mustafa Nazzal
- Center for Abdominal Transplantation, Saint Louis University, United States.
| | - Yifei Sun
- Department of General Surgery, Saint Louis University, United States
| | - Obi Okoye
- Department of General Surgery, Saint Louis University, United States
| | - Laurence Diggs
- Department of General Surgery, Saint Louis University, United States
| | - Neil Evans
- Saint Louis University School of Medicine, United States
| | - Tamara Osborn
- Saint Louis University School of Medicine, United States
| | - Kambiz Etesami
- Center for Abdominal Transplantation, Saint Louis University, United States
| | - Chintalapati Varma
- Center for Abdominal Transplantation, Saint Louis University, United States
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29
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Choice of Allograft in Patients Requiring Intestinal Transplantation: A Critical Review. Can J Gastroenterol Hepatol 2017; 2017:1069726. [PMID: 28553630 PMCID: PMC5434314 DOI: 10.1155/2017/1069726] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 04/05/2017] [Indexed: 02/06/2023] Open
Abstract
Intestinal transplantation (ITx) is indicated in patients with irreversible intestinal failure (IF) and life-threatening complications related to total parenteral nutrition (TPN). ITx can be classified into three main types. Isolated intestinal transplantation (IITx), that is, transplantation of the jejunoileum, is indicated in patients with preserved liver function. Combined liver-intestine transplantation (L-ITx), that is, transplantation of the liver and the jejunoileum, is indicated in patients with liver failure related to TPN. Thus, patients with cirrhosis or advanced fibrosis should receive a combined allograft, while patients with lower grades of liver fibrosis can usually safely undergo ITx. Reflecting their degree of sickness, the waitlist mortality rate and the early posttransplant outcomes of patients receiving L-ITx are worse than IITx. However, L-ITx is associated with better long-term graft and patient survival. Multivisceral transplantation (MVTx), that is, transplantation of the organs dependent on the celiac axis and superior mesenteric artery, can be classified into full MVTx if it includes the liver and modified MVTx if it does not. The most common indications for MVTx are extensive portomesenteric thrombosis and diffuse gastrointestinal pathology such as motility disorders and polyposis syndrome. Every patient with IF should undergo a multidisciplinary evaluation by an experienced ITx team.
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30
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Matsumoto R, Uchida K, Nishida S, Island E, Levi D, Fan J, Tekin A, Selvaggi G, Tzakis A. Extra-anatomical Meso-portal Venous Jump Graft Repair for Early Portal Vein Thrombosis After Liver Transplant in an Infant With a Hypoplastic Portal Vein: A Case Report. Transplant Proc 2016; 48:3186-3190. [DOI: 10.1016/j.transproceed.2016.08.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 07/29/2016] [Accepted: 08/22/2016] [Indexed: 01/10/2023]
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31
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Use of Left Gastric Vein as an Alternative for Portal Flow Reconstruction in Liver Transplantation. Case Rep Surg 2016; 2016:8289045. [PMID: 27595034 PMCID: PMC4993930 DOI: 10.1155/2016/8289045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/18/2016] [Indexed: 02/07/2023] Open
Abstract
Portal vein thrombosis is observed in up to 10% of liver transplant candidates, hindering execution of the procedure. A dilated gastric vein is an alternative to portal vein reconstruction and decompression of splanchnic bed. We present two cases of patients with portal cavernoma and dilated left gastric vein draining splanchnic bed who underwent liver transplantation. The vein was dissected and sectioned near the cardia; the proximal segment was ligated with suture and the distal segment was anastomosed to the donor portal vein. Gastroportal anastomosis is an excellent option for portal reconstruction in the presence of thrombosis or hypoplasia. It allows an adequate splanchnic drainage and direction of hepatotrophic factors to the graft.
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Characterization of Portal Vein Thrombosis (Neoplastic Versus Bland) on CT Images Using Software-Based Texture Analysis and Thrombus Density (Hounsfield Units). AJR Am J Roentgenol 2016; 207:W81-W87. [PMID: 27490095 DOI: 10.2214/ajr.15.15928] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate the role of CT texture analysis and thrombus density (measured in Hounsfield units) in distinguishing between neoplastic and bland portal vein thrombosis (PVT) on portal venous phase CT. MATERIALS AND METHODS In this retrospective study, 117 contrast-enhanced CT studies of 109 patients were included for characterization of PVT. Assessment of PVT was performed by estimation of CT textural features using CT texture analysis software and measurement of attenuation values. For CT texture analysis, filtered and unfiltered images were assessed to quantify heterogeneity using a set of predefined histogram-based texture parameters. The Mann-Whitney U test and binary logistic regression were applied for statistical significance. ROC curves were used to identify accuracy and optimal cutoff values. RESULTS Of the 117 CT studies, 63 neoplastic thrombi and 54 bland thrombi were identified on the images. The two most discriminative CT texture analysis parameters to differentiate neoplastic from bland thrombus were mean value of positive pixels (without filtration, p < 0.001) and entropy (with fine filtration, p < 0.001). Mean thrombus density values could also reliably distinguish neoplastic (81.39 HU) and bland (32.88 HU) thrombi (p < 0.001). The AUCs were 0.97 for mean value of positive pixels (p < 0.001), 0.93 for entropy (p < 0.001), 0.99 for the model combining mean value of positive pixels and entropy (p < 0.001), 0.91 for thrombus density (p < 0.001), and 0.61 for the radiologist's subjective evaluation (p = 0.037). The optimal cutoffs values were 56.9 for mean value of positive pixels, 4.50 for entropy, and 54.0 HU for thrombus density. CONCLUSION CT texture analysis and CT attenuation values allow reliable differentiation between neoplastic and bland thrombi on a single portal venous phase CT examination.
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Kobe A, Dutkowski P, Müllhaupt B, Clavien PA, Pfammatter T. Liver retransplantation with cavoportal hemitransposition after percutaneous mesocaval shunt creation. Liver Transpl 2016; 22:1154-8. [PMID: 27096231 DOI: 10.1002/lt.24469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 04/03/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Adrian Kobe
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Beat Müllhaupt
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Pfammatter
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
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34
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Recent Trends in the Diagnosis and Management of Biliary Atresia in Developing Countries. Indian Pediatr 2016; 52:871-9. [PMID: 26499012 DOI: 10.1007/s13312-015-0735-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
NEED AND PURPOSE OF REVIEW Biliary atresia is a progressive obstructive cholangiopathy and is fatal if left untreated within 2 years of life. Delay in referral is because of difficulties in differentiating it from physiologic jaundice and identifying an abnormal stool color. This paper presents an overview on the diagnosis and discusses the current strategies in the management of this disease in developing countries. METHODS Articles were retrieved from the PubMed database using the terms biliary atresia, Kasai portoenterostomy and pediatric liver transplantation. Contents of the article are also based on personal experience of the authors. CONCLUSION A national screening program using stool color cards as part of standard care in the neonatal period will greatly improve early detection of biliary atresia. Outcomes will improve if it is diagnosed at the earliest after birth, the child is referred to an experienced pediatric hepatobiliary unit for evaluation, and undergoes an early Kasai procedure. If an early Kasai portoenterostomy is performed, nearly half of all children survive into adolescence, and about one-third are likely to have a long-term, symptom-free life with normal liver biochemistry. Sequential treatment combining Kasai as first line and liver transplantation as second line results in 90% survival for children with biliary atresia.
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35
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Laurian C, Zaitouna M, Mallios A, Marteau V, Gigou F. A Novel Technique of Ilio-Portal Venous Bypass to Relieve Symptoms of Pelvic Vein Congestion in a Patient with Inferior Vena Cava Agenesis. Ann Vasc Dis 2016; 9:55-7. [PMID: 27087875 DOI: 10.3400/avd.cr.15-00075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 12/07/2015] [Indexed: 11/13/2022] Open
Abstract
A 37 year old man known to have inferior vena cava agenesis, presented to our center with severe symptoms of pelvic venous congestion. Surgical approach was attempted by creating a bypass between the right external iliac vein and the portal vein using an autogenous venous bypass (superficial femoral vein). Over a three year follow up, the bypass remained patent with complete resolution of symptoms. The ilio-portal venous bypass suggests a surgical alternative that has not been previously described.
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Affiliation(s)
- Claude Laurian
- Department of Vascular Surgery, Saint Joseph Hospital, Paris, France
| | - Mazen Zaitouna
- Department of Vascular Surgery, Saint Joseph Hospital, Paris, France
| | | | | | - Frédéric Gigou
- Department of Vascular Surgery, Saint Joseph Hospital, Paris, France
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Mendoza-Sánchez F, Javier-Haro F, Mendoza-Medina DF, González-Ojeda A, Cortés-Lares JA, Fuentes-Orozco C. [Portal perfusion with right gastroepiploic vein flow in liver transplant]. CIR CIR 2016; 85:60-65. [PMID: 26769523 DOI: 10.1016/j.circir.2015.08.010] [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: 01/13/2015] [Accepted: 08/25/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Liver transplantation in patients with liver cirrhosis, portal vein thrombosis, and cavernous transformation of the portal vein, is a complex procedure with high possibility of liver graft dysfunction. It is performed in 2-19% of all liver transplants, and has a significantly high mortality rate in the post-operative period. Other procedures to maintain portal perfusion have been described, however there are no reports of liver graft perfusion using right gastroepiploic vein. CLINICAL CASE A 20 year-old female diagnosed with cryptogenic cirrhosis, with a Child-Pugh score of 7 points (class "B"), and MELD score of 14 points, with thrombosis and cavernous transformation of the portal vein, severe portal hypertension, splenomegaly, a history of upper gastrointestinal bleeding due to oesophageal varices, and left renal agenesis. The preoperative evaluation for liver transplantation was completed, and the right gastroepiploic vein of 1-cm diameter was observed draining to the infrahepatic inferior vena cava and right suprarenal vein. An orthotopic liver transplantation was performed from a non-living donor (deceased on January 30, 2005) using the Piggy-Back technique. Portal vein perfusion was maintained using the right gastroepiploic vein, and the outcome was satisfactory. The patient was discharged 13 days after surgery. CONCLUSIONS Liver transplantation was performed satisfactorily, obtaining an acceptable outcome. In this case, the portal perfusion had adequate blood flow through the right gastroepiploic vein.
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Affiliation(s)
- Federico Mendoza-Sánchez
- Unidad de Trasplantes, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Francisco Javier-Haro
- Departamento de Cirugía General, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Diego Federico Mendoza-Medina
- Unidad de Investigación en Epidemiología Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Alejandro González-Ojeda
- Unidad de Investigación en Epidemiología Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - José Antonio Cortés-Lares
- Unidad de Investigación en Epidemiología Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
| | - Clotilde Fuentes-Orozco
- Unidad de Investigación en Epidemiología Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México.
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37
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[Vascular reconstruction in visceral transplantation surgery]. Chirurg 2015; 87:114-8. [PMID: 26541451 DOI: 10.1007/s00104-015-0108-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Vascular reconstruction is obligatory in transplantation surgery. A differentiation is made between routine vascular reconstructions, which are required for all solid organ transplantations and special cases. Because of the shortage of organs it is often necessary to use organs with complex anatomical vascular prerequisites, which requires high vascular surgical expertise for individualized reconstruction. Non-routine reconstructions are often also necessary on the side of the recipient. This review article presents both the routine and exceptional types of reconstruction.
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Hepatic Vascular Control in Liver Transplant and Application in Gastrointestinal Surgery. J Gastrointest Surg 2015; 19:2074-8. [PMID: 25982119 DOI: 10.1007/s11605-015-2853-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/04/2015] [Indexed: 01/31/2023]
Abstract
Complete control of the hepatic vasculature is routine during liver transplantation and sometimes required in general surgical cases. Knowledge of approach and management to hepatic vasculature control can be lifesaving. This article offers our systematic approach to controlling hepatic vasculature, where these techniques can be applied in trauma, general surgical, and transplant settings.
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Systemic Venous Inflow to the Liver Allograft to Overcome Diffuse Splanchnic Venous Thrombosis. Gastroenterol Res Pract 2015; 2015:810851. [PMID: 26539214 PMCID: PMC4619939 DOI: 10.1155/2015/810851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 03/17/2015] [Indexed: 12/11/2022] Open
Abstract
Diffuse splanchnic venous thrombosis (DSVT), formerly defined as contraindication for liver transplantation (LT), is a serious challenge to the liver transplant surgeon. Portal vein arterialisation, cavoportal hemitransposition and renoportal anastomosis, and finally combined liver and small bowel transplantation are all possible alternatives to deal with this condition. Five patients with preoperatively confirmed extensive splanchnic venous thrombosis were transplanted using cavoportal hemitransposition (4x) and renoportal anastomosis (1x). Median follow-up was 58 months (range: 0,5 to 130 months). Two patients with previous radiation-induced peritoneal injury died, respectively, 18 days and 2 months after transplantation. The three other patients had excellent long-term survival, despite the fact that two of them needed a surgical reintervention for severe gastrointestinal bleeding. Extensive splanchnic venous thrombosis is no longer an absolute contraindication to liver transplantation. Although cavoportal hemitransposition and renoportal anastomosis undoubtedly are life-saving procedures allowing for ensuring adequate allograft portal flow, careful follow-up of these patients remains necessary as both methods are unable to completely eliminate the complications of (segmental) portal hypertension.
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McKenna GJ. Making the extraordinary, ordinary: renoportal bypass for complete portal vein thrombosis. Liver Transpl 2015; 21:275-6. [PMID: 25678340 DOI: 10.1002/lt.24091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 01/18/2015] [Indexed: 01/17/2023]
Affiliation(s)
- Greg J McKenna
- Department of Surgery, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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41
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Srivastava M, Kumaran V, Nundy S, Mehta N. Successful living donor liver transplantation with cavoportal hemitransposition in diffuse portomesenteric thrombosis. Liver Transpl 2015; 21:135-9. [PMID: 25267282 DOI: 10.1002/lt.24008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 09/10/2014] [Accepted: 09/16/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Manish Srivastava
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi, India
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Bieker TM. Sonographic Evaluation of a Cavoportal Hemitransposition Liver Transplant. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2014. [DOI: 10.1177/8756479314549195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Extensive portal vein thrombosis is no longer considered a contraindication for liver transplantation. With cavoportal hemitransposition (portal diversion) or other surgical techniques, patients with portal vein thrombosis who would otherwise succumb to their liver disease are able to receive a transplant. A series of three cases is presented describing the evaluation and liver transplant procedures in patients with portal vein thrombosis. Sonography is shown to be an important tool both for diagnosing portal vein thrombosis and evaluating the portal system following transplantation.
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Zhang K, Jiang Y, Lv LZ, Cai QC, Yang F, Hu HZ, Zhang XJ. Portal vein arterialization technique for liver transplantation patients. World J Gastroenterol 2014; 20:12359-12362. [PMID: 25232274 PMCID: PMC4161825 DOI: 10.3748/wjg.v20.i34.12359] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 04/02/2014] [Accepted: 04/23/2014] [Indexed: 02/06/2023] Open
Abstract
Liver transplantations were performed on two patients with hepatic failure caused by liver cirrhosis. Hard obsolete thrombi and portal venous sclerosis were observed in the major portal veins of both patients. The arteria colica media of one recipient and the portal vein of the donor were anastomosed end-to-end. The hepatic artery of the first donor was anastomosed end-to end with the gastroduodenal artery of the first recipient; meanwhile, the portal vein of the second donor was simultaneously anastomosed end- to-end with the common hepatic artery of the second recipient. The blood flow of the portal vein, the perfusion of the donor liver and liver function were satisfactory after surgery. Portal vein arterialization might be an effective treatment for patients whose portal vein reconstruction was difficult.
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When and why portal vein thrombosis matters in liver transplantation: a critical audit of 174 cases. Ann Surg 2014; 259:760-6. [PMID: 24299686 DOI: 10.1097/sla.0000000000000252] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify complications associated with different techniques utilized to treat portal vein thrombosis (PVT) during primary liver transplantation and their impact on survival. BACKGROUND PVT remains an intricate problem in liver transplantation, and the long-term outcomes of patients with PVT who undergo transplantation are not well defined. METHODS We performed a retrospective cohort analysis of all consecutive adult patients who underwent primary isolated liver transplantation from 1998 to 2009 (median follow-up period, 89 months). The outcomes of patients with PVT were compared with those without PVT. RESULTS Among 1379 recipients, 174 (12.6%) had PVT at the time of transplantation [83 (48%) complete and 91 (52%) partial]. Among PVT patients with reestablished physiological portal inflow (PVT: physiological group; n = 149), 123 underwent thrombectomies, 16 received interpositional vein grafts, and 10 received mesoportal jump grafts. In 25 patients, physiological portomesenteric venous circulation was not reconstituted (PVT: nonphysiological group; 18 underwent cavoportal hemitranspositions, 6 renoportal anastomoses, and 1 arterialization). The PVT: nonphysiological group suffered a significantly increased incidence of rethrombosis of the portomesenteric veins and gastrointestinal bleeding, with a marginal 10-year overall survival rate of 42% (no PVT, 61%; P = 0.002 and PVT: physiological, 55%; P = 0.043). The PVT: physiological and no PVT groups exhibited comparable survival rates (P = 0.13). No significant differences in survival were observed between complete and partial PVT as long as physiological portal flow was reestablished. CONCLUSIONS The subset of PVT patients requiring nonphysiological portal vein reconstruction was associated with higher complication rates and suffered diminished long-term prognoses. For the most severe PVT cases, a comprehensive approach is critical to further improve outcomes.
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Moon DB, Lee SG, Ahn CS, Hwang S, Kim KH, Ha TY, Song GW, Park GC, Jung DH, Namkoong JM, Park HW, Park YH. Restoration of portal flow using a pericholedochal varix in adult living donor liver transplantation for patients with total portosplenomesenteric thrombosis. Liver Transpl 2014; 20:612-5. [PMID: 24677674 DOI: 10.1002/lt.23850] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 01/30/2014] [Indexed: 02/07/2023]
Abstract
In total portosplenomesenteric thrombosis patients, cavoportal hemitransposition (CPHT) is indicated but rarely applicable for adult-to-adult (A-to-A) living donor liver transplantation (LDLT) because partial liver graft requires splanchno-portal inflow for liver graft regeneration. If intra- & peri-pancreatic collaterals draining into pericholedochal varix were present, pericholedochal varix may provide splanchnic blood flow to the transplanted liver and also relieve recipient's portal hypertension. To date, however, there is no successful report using pericholedochal varix in liver transplantation (LT). We successfully performed A-to-A LDLTs using pericholedochal varix for those 2 patients. The surgical strategies are followings: (a) dissection of hepatic hilum to isolate left hepatic artery using for arterial reconstruction of implanted right lobe graft, (b) en-mass clamping of the undissected remaining hilum if we can leave adequate length of stump from the clamping site, and then hilum is divided, (c) delay the donor hepatectomy until the feasibility of the recipient operation is confirmed. Portal flow was established between the sizable pericholedochal varix (caliber > 1cm) and graft portal vein, but the individually designed approaches were used for each patients. Currently, they have been enjoying normal life on posttransplant 92 and 44 months respectively. In conclusion, enlarged pericholedochal varix in patients with totally obliterated splanchnic veins might be an useful inflow to restore portal flow and secure good outcome in A-to-A LDLT. AASLD.
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Affiliation(s)
- Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Section 6. Management of Extensive Nontumorous Portal Vein Thrombosis in Adult Living Donor Liver Transplantation. Transplantation 2014; 97 Suppl 8:S23-30. [DOI: 10.1097/01.tp.0000446270.20934.05] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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47
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Yagi T, Nobuoka D, Shinoura S, Umeda Y, Sato D, Yoshida R, Utsumi M, Fuji T, Sadamori H, Fujiwara T. First successful case of simultaneous liver and kidney transplantation for patients with chronic liver and renal failure in Japan. Hepatol Res 2014; 44:358-63. [PMID: 23607507 DOI: 10.1111/hepr.12122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 03/14/2013] [Accepted: 03/27/2013] [Indexed: 02/08/2023]
Abstract
Establishment of a preferential liver allocation rule for simultaneous liver and kidney transplantation (SLK) and revisions of laws regarding organ transplants from deceased donors have paved the way for SLK in Japan. Very few cases of SLK have been attempted in Japan, and no such recipients have survived for longer than 40 days. The present report describes a case of a 50-year-old woman who had undergone living donor liver transplantation at the age of 38 years for management of post-partum liver failure. After the first transplant surgery, she developed hepatic vein stenosis and severe hypersplenism requiring splenectomy. She was then initiated on hemodialysis (HD) due to the deterioration of renal function after insertion of a hepatic vein stent. She was listed as a candidate for SLK in 2011 because she required frequent plasma exchange for hepatic coma. When her Model for End-stage Liver Disease score reached 46, the new liver was donated 46 days after registration. The reduced trisegment liver and the kidney grafts were simultaneously transplanted under veno-venous bypass and intraoperative HD. The hepatic artery was reconstructed prior to portal reconstruction in order to shorten anhepatic time. Although she developed subcapsular bleeding caused by hepatic contusion on the next day, subsequent hemostasis was obtained by transcatheter embolization. Thereafter, her recovery was uneventful, except for mild rejection and renal tubular acidosis of the kidney graft. This case highlights the need to establish Japanese criteria for SLK.
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Affiliation(s)
- Takahito Yagi
- Hepato-Biliary and Pancreatic Surgery, Okayama University Hospital, Okayama, Japan
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Ponziani FR, Zocco MA, Senzolo M, Pompili M, Gasbarrini A, Avolio AW. Portal vein thrombosis and liver transplantation: implications for waiting list period, surgical approach, early and late follow-up. Transplant Rev (Orlando) 2014; 28:92-101. [PMID: 24582320 DOI: 10.1016/j.trre.2014.01.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 09/19/2013] [Accepted: 01/19/2014] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT) is a well-known and relatively common complication of liver cirrhosis. In the past, PVT was considered as a contraindication for liver transplantation (LT). To characterize prevalence, risk factors, perioperative management and outcome of PVT in the setting of LT, the English literature published between 1991 and 2011 was reviewed. Of 6807 articles, 280 were selected, and 39 experiences were analyzed in detail (methodology, type and duration of treatments, peri-operative management, strategy to avoid recurrence, strengths and weaknesses, Oxford evidence level, citations). 3/39 studies were prospective; 9/39 were based on prospectively recorded databases; no studies of 1, 2a, 3a level of evidence were present; 5/39 were recognized as level 2b, 23/39 as level 3b, and 8/39 as level 4. High complication rate has been reported with consequent effect on graft and patient survival. Overall, PVT presents today good results similar to those obtained in patients without PVT undergoing LT even if they require a higher transfusion number and a longer ICU/hospital stay. Reported cases were retrospectively stratified according to Yerdel classification. Grade 1-2 patients (76%) do well with eversion thromboendovenectomy, resection of damaged vein and porto-portal anastomosis. Results of patients with grade 3-4 (24%) are inferior, however data on outcome in this subsets are fragmented and do not allow a reliable analysis. Moreover, results obtained in grade 3-4 cases are better in transplant centers with large specific experience. The small number of reports suggests caution. The role of anticoagulant treatment is still debated. Although in cirrhotics with PVT LT remains a demanding procedure, PVT should not be considered a contraindication anymore.
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Affiliation(s)
- Francesca Romana Ponziani
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy.
| | - Maria Assunta Zocco
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Marco Senzolo
- Department of surgical, Oncological, and Gastroenterological Sciences University hospital of Padua, Padua, Italy
| | - Maurizio Pompili
- Department of Internal Medicine, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Alfonso Wolfango Avolio
- Department of Surgical Sciences, Division of General Surgery and Organs Transplantation, Catholic University, Agostino Gemelli Hospital, Rome, Italy
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Memeo R, Salloum C, Subar D, de'Angelis N, Zantidenas D, Compagnon P, Laurent A, Azoulay D. Transformation of cavoportal inflow to renoportal inflow to the graft during liver transplantation for stage IV portal vein thrombosis. Liver Transpl 2013; 19:776-7. [PMID: 23536491 DOI: 10.1002/lt.23651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 03/19/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Riccardo Memeo
- Digestive Surgery and Liver Transplantation Unit; Henri Mondor Hospital, University of Paris; Créteil; France
| | - Chady Salloum
- Digestive Surgery and Liver Transplantation Unit; Henri Mondor Hospital, University of Paris; Créteil; France
| | - Daren Subar
- Department of General and Hepatobiliary-Pancreatic Surgery; Blackburn Royal Hospital; Blackburn; United Kingdom
| | - Nicola de'Angelis
- Digestive Surgery and Liver Transplantation Unit; Henri Mondor Hospital, University of Paris; Créteil; France
| | - David Zantidenas
- Department of Hepatology; Sainte Camille Hospital; Bry sur Marne; France
| | - Philippe Compagnon
- Digestive Surgery and Liver Transplantation Unit; Henri Mondor Hospital, University of Paris; Créteil; France
| | - Alexis Laurent
- Digestive Surgery and Liver Transplantation Unit; Henri Mondor Hospital, University of Paris; Créteil; France
| | - Daniel Azoulay
- Digestive Surgery and Liver Transplantation Unit; Henri Mondor Hospital, University of Paris; Créteil; France
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Paloyo S, Nishida S, Fan J, Tekin A, Selvaggi G, Levi D, Tzakis A. Portal vein arterialization using an accessory right hepatic artery in liver transplantation. Liver Transpl 2013; 19:773-5. [PMID: 23554089 DOI: 10.1002/lt.23653] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 03/26/2013] [Indexed: 01/12/2023]
Abstract
Portal vein thrombosis remains to be a challenging issue during liver transplantation even with the acquisition of innovative surgical techniques and years of experience. Most frequently, an initial eversion thromboendovenectomy is performed and depending on the extent of thrombosis and intraoperative findings, further revascularization options include venous jump grafts, portocaval hemitransposition, renoportal anastomosis or portal vein arterialization. Reports on these surgical approaches are limited although with acceptable outcomes. We present a 64-year-old patient with hepatitis C cirrhosis who underwent orthotopic liver transplantation with portal vein arterialization using an accessory right hepatic artery. Liver graft function has remained stable four years after transplant with notable aneurysmal dilatation of the portal vein.
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Affiliation(s)
- Siegfredo Paloyo
- Division of Transplantation, Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.
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