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Nagata R, Akamatsu N, Shibata E, Takao H, Ichida A, Mihara Y, Kawaguchi Y, Ishizawa T, Kaneko J, Arita J, Tamura S, Abe O, Hasegawa K. Metallic Stents for Hepatic Venous Outflow Obstruction After Living-Donor Liver Transplantation and their Therapeutic Effects. Transplant Proc 2024; 56:125-134. [PMID: 38177046 DOI: 10.1016/j.transproceed.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/26/2023] [Accepted: 11/30/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Living-donor liver transplantation (LDLT) is established as a standard therapy for end-stage liver disease; however, vessel reconstruction is more demanding due to the short length and small size of the available structures compared with deceased-donor whole liver transplantation. Interventional radiology (IR) has become the first-line treatment for vascular complications after LDLT. Hepatic venous outflow obstruction (HVOO) is a life-threatening complication after LDLT. The aim of this study of 592 adult-to-adult LDLT cases was to investigate the safety and efficacy of stent implantation for HVOO after LDLT. METHODS Records of patients who developed HVOO requiring any treatment were collected with special reference to the metallic stent implantation. There were 232 left-side grafts and 360 right-side grafts. Sixteen cases developed HVOO after LDLT with an incidence rate of 2.7%, 5 with a left liver graft (2%), and 11 with a right-side graft (3%). The IR was attempted for 14 cases; among those, 8 cases were treated by stent implantation. RESULTS The technical success rate of the initial stent implantation was 100%. The pressure gradient at the stenotic site significantly improved from 12.2 (range, 10.9-20.4 cm H2O) to 3.9 cm H2O (range, 1.4-8.2 cm H2O; P = .03). The volume of the congested graft liver decreased significantly from 1448 (range, 788-2170 mL) to 1265 mL (range, 748-1665 mL; P = .01), and the serum albumin level improved significantly from 3.3 (range, 1.7-3.7 g/dL) to 3.7 g/dL (range, 2.9-4.1 g/dL; P = .02). No procedure-related complication was noted, and the long-term stent patency was 100%. CONCLUSION Metallic stent implantation for stenotic venous anastomosis after LDLT is a safe and effective treatment.
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Affiliation(s)
- Rihito Nagata
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Eisuke Shibata
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Hidemasa Takao
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Akihiko Ichida
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Yuichiro Mihara
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Takeaki Ishizawa
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Junichi Kaneko
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Junichi Arita
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Sumihito Tamura
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Osamu Abe
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Tokyo, Japan.
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Minciuna I, den Hoed C, van der Meer AJ, Sonneveld MJ, Sprengers D, de Knegt RJ, de Jonge J, Maan R, Polak WG, Darwish Murad S. The Yield of Routine Post-Operative Doppler Ultrasound to Detect Early Post-Liver Transplantation Vascular Complications. Transpl Int 2023; 36:11611. [PMID: 38093807 PMCID: PMC10716223 DOI: 10.3389/ti.2023.11611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023]
Abstract
Early detection of liver transplantation (LT) vascular complications enables timely management. Our aim was to assess if routine Doppler ultrasound (rDUS) improves the detection of hepatic artery thrombosis (HAT), portal vein thrombosis (PVT) and hepatic venous outflow obstruction (HVOO). We retrospectively analysed timing and outcomes, number needed to diagnose one complication (NND) and positive predictive value (PPV) of rDUS on post-operative day (POD) 0,1 and 7 in 708 adult patients who underwent primary LT between 2010-2022. We showed that HAT developed in 7.1%, PVT in 8.2% and HVOO in 3.1% of patients. Most early complications were diagnosed on POD 0 (26.9%), 1 (17.3%) and 5 (17.3%). rDUS correctly detected 21 out of 26 vascular events during the protocol days. PPV of rDUS was 53.8%, detection rate 1.1% and NND was 90.5. Median time to diagnosis was 4 days for HAT and 47 days for PVT and 21 days for HVOO. After intervention, liver grafts were preserved in 57.1%. In conclusion, rDUS protocol helps to detect first week's vascular events, but with low PPV and a high number of ultrasounds needed.
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Affiliation(s)
- Iulia Minciuna
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department V- Gastroenterology, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Cluj-Napoca, Romania
| | - Caroline den Hoed
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Adriaan J. van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Milan J. Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Dave Sprengers
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Robert J. de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jeroen de Jonge
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Wojciech G. Polak
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
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Goiffon RJ, Kambadakone AR. Deceased Donor Liver Transplantation: Techniques and Surgical Anatomy. Radiol Clin North Am 2023; 61:761-769. [PMID: 37495285 DOI: 10.1016/j.rcl.2023.04.001] [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: 07/28/2023]
Abstract
Deceased liver donor transplantation is increasing in prevalence resulting in larger volumes of posttransplant imaging studies. Radiologists should familiarize themselves with the spectrum of normal posttransplant anatomy. The key findings can be categorized into 4 systems reconstructed during surgery: hepatic venous, portal venous, hepatic arterial, and biliary ductal systems. Here we discuss the imaging findings seen with the most common surgical techniques, those that can be misidentified as complications, and some less common variations resulting from different surgical techniques.
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Affiliation(s)
- Reece J Goiffon
- Department of Radiology, Division of Abdominal Imaging, Massachusetts General Hospital, 55 Fruit Street, White 270 Boston, MA 02114, USA.
| | - Avinash R Kambadakone
- Department of Radiology, Division of Abdominal Imaging, Massachusetts General Hospital, 55 Fruit Street, White 270 Boston, MA 02114, USA
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Kruk E, Kalinowski P, Gibiński K, Dudek K, Skalski M, Przybysz M, Zhylko A, Nazarewski Ł, Morawski M, Grąt M. Stapled Anastomosis for Side-to-Side Cavo-Cavostomy in Orthotopic Liver Transplantation. J Clin Med 2023; 12:5289. [PMID: 37629332 PMCID: PMC10455895 DOI: 10.3390/jcm12165289] [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: 07/09/2023] [Revised: 07/26/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
In liver transplantation, a side-to-side anastomosis is one of the commonly performed techniques of the inferior vena cava reconstruction. The authors report a case of an application of an endoscopic vascular linear stapler for a side-to-side caval anastomosis during deceased-donor liver transplantation. The back table procedure was performed in a standard fashion for a side-to-side anastomosis. The linear vascular stapler was introduced during the temporary clamping of the recipient's inferior vena cava and the anastomosis was created without problems. Suturing of the resulting defect completed the anastomosis. The use of the stapler resulted in a shortening of the anastomosis time. The staple line after the reperfusion of the graft was completely sealed. The patient's postoperative course was uncomplicated and post-operative ultrasound and computed tomography confirmed the patency of the anastomosis. This case demonstrates a novel approach to a side-to-side caval reconstruction during liver transplantation that enables a shortening of the implantation time and may improve the quality of anastomoses.
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Affiliation(s)
- Emilia Kruk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland; (E.K.); (M.G.)
| | - Piotr Kalinowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland; (E.K.); (M.G.)
| | - Krzysztof Gibiński
- 2nd Department of Clinical Radiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Krzysztof Dudek
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland; (E.K.); (M.G.)
| | - Michał Skalski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland; (E.K.); (M.G.)
| | - Marta Przybysz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland; (E.K.); (M.G.)
| | - Andriy Zhylko
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland; (E.K.); (M.G.)
| | - Łukasz Nazarewski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland; (E.K.); (M.G.)
| | - Marcin Morawski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland; (E.K.); (M.G.)
| | - Michał Grąt
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland; (E.K.); (M.G.)
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Pull-through technique for hepatic vein angioplasty after liver transplantation. Radiol Case Rep 2023; 18:996-999. [PMID: 36684619 PMCID: PMC9849983 DOI: 10.1016/j.radcr.2022.11.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 11/27/2022] [Indexed: 01/07/2023] Open
Abstract
Hepatic venous outflow complication is one of the crucial vascular complications after liver transplantation. We describe successful use of the pull-through technique for hepatic vein angioplasty in a patient with stenosis of the middle and left hepatic veins (MHV and LHV) after living-donor liver transplantation. It was difficult to select the stenotic MHV with a femoral approach. However, the guidewire was unexpectedly inserted into a small collateral vein and selective angiography showed the MHV through the collaterals. Because the guidewire proceeded to the MHV via the collateral and finally into the inferior vena cava, we advanced a catheter from the inferior vena cava to the MHV using the pull-through technique and performed balloon angioplasty.
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6
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Understanding Local Hemodynamic Changes After Liver Transplant: Different Entities or Simply Different Sides to the Same Coin? Transplant Direct 2022; 8:e1369. [PMID: 36313127 PMCID: PMC9605796 DOI: 10.1097/txd.0000000000001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/13/2022] [Accepted: 06/28/2022] [Indexed: 12/02/2022] Open
Abstract
Liver transplantation is an extremely complex procedure performed in an extremely complex patient. With a successful technique and acceptable long-term survival, a new challenge arose: overcoming donor shortage. Thus, living donor liver transplant and other techniques were developed. Aiming for donor safety, many liver transplant units attempted to push the viable limits in terms of size, retrieving smaller and smaller grafts for adult recipients. With these smaller grafts came numerous problems, concepts, and definitions. The spotlight is now aimed at the mirage of hemodynamic changes derived from the recipients prior alterations. This article focuses on the numerous hemodynamic syndromes, their definitions, causes, and management and interconnection with each other. The aim is to aid the physician in their recognition and treatment to improve liver transplantation success.
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Maria Silva A, Reis Waisberg D, Ribeiro Fernandes M, Martino RB, Rocha-Santos V, Pinheiro RS, Nacif LS, Arantes RM, Ducatti L, Galvão FH, Lee AD, Haddad LB, Silva NA, Dala Riva DF, Moreira AM, Oliveira RA, Carnevale FC, Andraus W, Carneiro-D Albuquerque LA. Hepatic Venous Outflow Obstruction in Adult Deceased Donor Liver Transplantation: Classic Piggyback Implantation Versus a Modified Technique that Widens the Ostium of the Recipient's Left and Middle Hepatic Veins. Transplant Proc 2022; 54:1316-1319. [PMID: 35659781 DOI: 10.1016/j.transproceed.2022.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The classic piggyback technique uses the union of the 3 hepatic veins to perform the cavo-caval anastomosis. However, due to the lateral localization of the right hepatic vein, the partial clamping of the vena cava in this technique significantly reduces the venous return to the right atrium. To avoid this, we adopted in 2015 a modified piggyback technique, in which we use the common trunk of the middle and left hepatic veins and also perform a lateral incision toward the right in the anterior wall of the vena cava in order to widen the final ostium of the cavo-caval anastomosis. The aim of the study was to analyze the incidence of hepatic venous outflow obstruction between those 2 techniques. METHODS Retrospective study of liver transplant recipients undergoing venography for suspected hepatic venous outflow obstruction from January 2009 to June 2021. Patients undergoing transplantation with living donors or split grafts and pediatric cases were excluded from the study. RESULTS From January 2009 to December 2014 and from January 2015 to June 2021, 587 (group 1) and 730 (group 2) deceased-donor liver transplants were performed with the classic and the modified piggyback techniques, respectively. The incidence of cases with suspected hepatic venous outflow obstruction in groups 1 and 2 were 1.87% (n = 11) and 0.95% (n = 7), respectively (P = 0,15). The number of confirmed patients with outflow blockage that required endovascular treatment during venography in groups 1 and 2 were 4 (0.68%) and 5 (0.68%), respectively (P = 0,31). CONCLUSIONS This modified piggyback technique did not increase the incidence of hepatic venous outflow obstruction at our service.
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Affiliation(s)
- Amanda Maria Silva
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Daniel Reis Waisberg
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil.
| | - Michel Ribeiro Fernandes
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Rodrigo Bronze Martino
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Vinicius Rocha-Santos
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Rafael Soares Pinheiro
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Lucas Souto Nacif
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Rubens Macedo Arantes
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Liliana Ducatti
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Flávio Henrique Galvão
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil; Laboratory of Medical Investigation 37, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Andre Dong Lee
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Luciana Bertocco Haddad
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil; Laboratory of Medical Investigation 37, University of Sao Paulo Medical School, Sao Paulo, Brazil; Interventional Radiology Division, Department of Radiology, Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, Brazil
| | - Nataliê Almeida Silva
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Daniel Fernandes Dala Riva
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Airton Mota Moreira
- Interventional Radiology Division, Department of Radiology, Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, Brazil
| | - Ricardo Abdala Oliveira
- Interventional Radiology Division, Department of Radiology, Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, Brazil
| | - Francisco César Carnevale
- Interventional Radiology Division, Department of Radiology, Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, Brazil
| | - Wellington Andraus
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil; Laboratory of Medical Investigation 37, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Luiz Augusto Carneiro-D Albuquerque
- Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil; Laboratory of Medical Investigation 37, University of Sao Paulo Medical School, Sao Paulo, Brazil
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Outcomes in Adult Liver Transplant Recipients Using Pediatric Deceased Donor Liver Grafts. Transplant Direct 2022; 8:e1315. [PMID: 35415214 PMCID: PMC8989770 DOI: 10.1097/txd.0000000000001315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/04/2022] [Accepted: 02/17/2022] [Indexed: 11/27/2022] Open
Abstract
Background. The use of pediatric grafts for liver transplantation (LT) into adult recipients is rare, and reported outcomes are conflicting. The aim of this study is to evaluate the outcomes in adult recipients following LT with grafts from deceased pediatric donors. Methods. A retrospective study identifying adult LT between 2010 and 2020 using pediatric deceased donor liver grafts was conducted. Adults undergoing LT with deceased donor pediatric grafts (age ≤ 12) were identified and matched 1:2 with adults receiving adult grafts (age ≥ 18) based on recipient age (±10 y), model for end-stage liver disease (MELD) score at transplant (±5 points) and etiology of liver disease. To assess real liver size differences between the pediatric-donor and adult-donor groups, patients receiving a graft from a donor between 13 and 17 y were excluded from the main analysis and studied independently. Outcomes between the groups were compared. Complication rates were identified and graded using Clavien–Dindo classification. Graft and patient survival were assessed by Kaplan–Meier curves. Results. Twelve adult LT recipients with whole liver grafts from deceased pediatric donors were matched with 24 adult recipients of adult donors. Recipient age and MELD score were similar between groups. Recipients of pediatric grafts were more likely to be female (66.7% versus 16.7%, P = 0.007) and leaner (body mass index = 24.4 versus 29.9, P = 0.013). Alcohol-related cirrhosis was the most prevalent liver disease etiology in both groups (P = 0.96). There was no significant difference in length of stay, readmissions, early complications, or major complications between groups. Vascular and biliary complication rates were similar. Actuarial graft and patient survival at 1, 3, and 5 y were 100/100/100 versus 96/96/96 (P = 0.48). Conclusions. Excellent patient and graft survival is achievable with LT using young pediatric deceased donor grafts in smaller adult recipients. Outcomes are comparable with recipients of age and MELD-matched adult donors. Careful donor MELD-score recipient matching and close monitoring for potential biliary and vascular complications are crucial to achieve acceptable outcomes.
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Balancing the tug of war: intraoperative and postoperative management of multiorgan transplantation. Curr Opin Organ Transplant 2022; 27:57-63. [PMID: 34939965 DOI: 10.1097/mot.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Multiorgan heart transplants (MOHT) have steadily increased and account for approximately 4% of all heart transplants performed. Although long-term outcomes of MOHT are similar to heart transplant alone, perioperative management remains an issue with nearly double the rate of prolonged hospitalization. Better understanding of hemodynamic environments encountered and appropriate therapeutic targets can help improve perioperative management. RECENT FINDINGS Accurate and precise hemodynamic monitoring allows for early identification of complications and prompt assessment of therapeutic interventions. This can be achieved with a multimodal approach using traditional monitoring tools, such a pulmonary artery catheter and arterial line in conjunction with transesophageal echocardiography. Specific targets for optimizing graft perfusion are determined by phase of surgery and organ combination. In some circumstances, the surgical sequence of transplant can help mitigate or avoid certain detrimental hemodynamic environments. SUMMARY With better understanding of the array of hemodynamic environments that can develop during MOHT, we can work to standardize hemodynamic targets and therapeutic interventions to optimize graft perfusion. Effectively navigating this perioperative course with multimodal monitoring including transesophageal echocardiography can mitigate impact of complications and reduce prolonged hospitalization associated with MOHT.
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Chen Z, Ju W, Chen C, Wang T, Yu J, Hong X, Dong Y, Chen M, He X. Application of various surgical techniques in liver transplantation: a retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1367. [PMID: 34733919 PMCID: PMC8506559 DOI: 10.21037/atm-21-1945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/15/2021] [Indexed: 12/17/2022]
Abstract
Background Surgical techniques of liver transplantation have continually evolved and have been modified. We retrospectively analyzed a single-center case series and compared the advantages and disadvantages of each method. Methods Six-hundred and seventy-four recipients’ perioperative data were assessed and analyzed stratified by different surgical technics [modified classic (MC), modified piggyback (MPB) and classic piggyback (CPB)]. Results MELD score and Child-Pugh scores was significantly higher in CPB groups (P=0.008 and 0.003, respectively). Anhepatic time in MPB group was longer than those in CPB group (P<0.05). The operation duration in MPB group was significantly longer than those in MC group and CPB group (P=0.003). Three patients had outflow obstruction (P=0.035). The overall survival in MPB group were better than those in MC group and CPB group in general comparison (P<0.001). In patients with preoperative creatine >120 µmol/L, the overall survival in MC group was worst (P<0.001). In patients with a high MELD score (>24), the overall survival in MPB group tended to be the best (P<0.001). Conclusions The advantages and disadvantages are different for these three surgical techniques. A reasonable operation technique should be adopted considering the patient's unique condition to ensure the stability of hemodynamics.
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Affiliation(s)
- Zhitao Chen
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Weiqiang Ju
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Chuanbao Chen
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Tielong Wang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Jia Yu
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Xitao Hong
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yuqi Dong
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Maogen Chen
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Xiaoshun He
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
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11
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Fabes J, Spiro M, Research Group RFP. Prospective Cohort Study Assessing the Use of Peripheral Saphenous Venous Pressure Monitoring as a Marker of the Transcaval Venous Pressure Gradient in Liver Transplant Surgery. EXP CLIN TRANSPLANT 2021; 19:1291-1297. [PMID: 34763624 DOI: 10.6002/ect.2021.0288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Assessment of the transcaval venous pressure gradient, the central venous to inferior vena caval pressure, assists anesthetists and surgeons in management of liver transplant recipients. Traditionally, this entails insertion of a femoral central line with increased patient risk and health care cost. Here, we assessed the ability of a saphenous vein cannula to act as a surrogate for the femoral central line as a means to assess the transcaval pressure gradient in a safer and less invasive manner. MATERIALS AND METHODS A prospective cohort of 22 patients undergoing liver transplant underwent saphenous vein cannulation in addition to insertion of a femoral and internal jugular central venous catheter. Data were collected throughout each phase of surgery to assess the central, femoral, and saphenous vein pressures; results of a range of relevant physiological and ventilatory data were also collected. RESULTS The primary outcome, the correlation between saphenous and femoral venous pressure throughout surgery, was acceptable (r2 = 0.491, P < .001). During the anhepatic phase of surgery, this correlation improved (r2 = 0.912, P < .001). The correlation between the femoral to central venous pressure and saphenous to central venous pressure gradients was also reasonable throughout surgery (r2 = 0.386, P < .001), and this correlation was significantly stronger during the anhepatic phase (r2 = 0.935, P < .001). CONCLUSIONS Saphenous venous pressure, provided by peripheral cannulation, provided a reliable, less invasive, and safer alternative to femoral central line insertion for determination of the transcaval pressure gradient during the anhepatic phase of liver transplant.
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Affiliation(s)
- Jeremy Fabes
- From the Department of Anaesthesia, The Royal Free NHS Foundation Trust, London, United Kingdom.,From the Faculty of Health, University of Plymouth, Plymouth, United Kingdom
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12
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Cubisino A, Leon P, Navarro F, Panaro F. One-shot side-to-side anastomosis (OSSSA) with stapler for cavo-cavostomy in liver transplantation: the first step towards a fully mechanized liver transplant? Langenbecks Arch Surg 2021; 406:1711-1715. [PMID: 34191124 DOI: 10.1007/s00423-021-02254-1] [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: 03/31/2021] [Accepted: 06/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND In literature, a variety of caval reconstruction techniques for liver transplantation have been reported. The piggyback technique preserves the recipient's caval vein which is directly anastomosed to donor's inferior vena cava (IVC) allowing for the reduction of hemodynamic compromise during liver transplantation. METHODS Herein, we present our standardized step-by-step technique for the realization of a caval one-shot side-to-side anastomosis (OSSSA) using a linear stapler. A Satinsky vascular clamp is placed in a top down direction to realize a longitudinal partial clamping of the recipient IVC. A 1-cm venotomy is then performed on the anterior wall of the recipient IVC to permit the easy introduction of the vascular stapler arm in order to perform the mechanical anastomosis. Portal vein, hepatic artery, and biliary anastomosis are then completed in standard fashion. CONCLUSIONS Compared to the manual one, this mechanical anastomosis permits to reduce operative time, caval and portal vein clamping, warm ischemia time, and visceral congestion. RESULTS In our opinion, this is a rapid, easy, safe, and reproducible technique to perform the side-to-side cavocaval anastomosis during liver transplantation in selected patients when a manual anastomosis may be technically challenging.
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Affiliation(s)
- Antonio Cubisino
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Hôpital Saint Eloi, CHU-Montpellier, 80 Av. Augustin Fliche, 34295, Montpellier, France.
| | - Piera Leon
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Hôpital Saint Eloi, CHU-Montpellier, 80 Av. Augustin Fliche, 34295, Montpellier, France
| | - Francis Navarro
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Hôpital Saint Eloi, CHU-Montpellier, 80 Av. Augustin Fliche, 34295, Montpellier, France
| | - Fabrizio Panaro
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Hôpital Saint Eloi, CHU-Montpellier, 80 Av. Augustin Fliche, 34295, Montpellier, France
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13
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Oliver CM, Fabes J, Ingram N, Rahman S, Krzanicki D, Spiro M. Not All Piggybacks Are Equal: A Retrospective Cohort Analysis of Variation in Anhepatic Transcaval Pressure Gradient and Acute Kidney Injury During Liver Transplant. EXP CLIN TRANSPLANT 2021; 19:539-544. [PMID: 34085605 DOI: 10.6002/ect.2021.0050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Complete inferior vena cava clamping in cavalreplacement during livertransplantis associated with substantial physiological derangement and postoperative morbidity. Partial clamping in the piggyback technique may be relatively protective, but evidence is lacking. Having observed substantial variation in transhepatic inferior vena cava pressure gradient with piggyback, we hypothesized that the causative mechanism is the extent of caval clamping rather than the surgical approach. MATERIALS AND METHODS We used internal jugular and femoral catheters to estimate suprahepatic and infrahepatic inferior vena cava pressures during clamping. Pressure gradients were calculated, and distributions were compared by surgical technique. We estimated adjusted odds ratios for pressure gradient on acute kidney injury at 72 hours. RESULTS In 115 case records, we observed substantial variation in maximum pressure gradient; median values were 18.0 mm Hg(interquartile range, 8.0-25.0 mm Hg) with the piggyback technique and 24.0 mm Hg (interquartile range, 19.5-27.0 mm Hg) with caval replacement. Incidence of acute kidney injury was 25% (29 patients). Pressure gradient was linearly associated with probability of acute kidney injury (odds ratio, 1.06; 95% CI, 1.01-1.13). CONCLUSIONS We report 2 novel findings. (1) Anhepatic inferior vena cavapressuregradient variedsubstantially in individuals undergoing piggyback, and (2) gradient was positively associatedwith early acute kidney injury. We hypothesize that this (unmeasured) variation explains the conflictingfindings ofprevious studies that compared surgical techniques. Also, we propose that caval pressure gradient could be routinely assessed to optimize real-time piggyback clamp position during livertransplant surgery.
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Affiliation(s)
- Charles M Oliver
- From the Centre for Perioperative Medicine, Research Division of Targeted Intervention, University College London, Charles Bell House
| | - Jez Fabes
- From the Department of Anaesthesia, The Royal Free London NHS Foundation Trust, London, United Kingdom
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14
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Laroche S, Maulat C, Kitano Y, Golse N, Azoulay D, Sa Cunha A, Vibert E, Adam R, Cherqui D, Allard MA. Initial piggyback technique facilitates late liver retransplantation - a retrospective monocentric study. Transpl Int 2021; 34:835-843. [PMID: 33650170 DOI: 10.1111/tri.13857] [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: 11/17/2020] [Revised: 01/04/2021] [Accepted: 02/26/2021] [Indexed: 11/28/2022]
Abstract
Optimal management of inferior vena cava (IVC) is crucial to ensure safety in late liver retransplantation (ReLT). The aim of this study was to evaluate different surgical strategies with regard to IVC in late ReLT. All consecutive late ReLT (≥90 days from the previous transplant) from 2013 to 2018 in a single center was reviewed (n = 66). Of them, 46 (69.7%) were performed without venovenous bypass (VVB) including 29 with caval preservation (CP) and 17 with caval replacement (CR). The remaining 20 cases (30.3%) required the use of VVB. Among ReLT without VVB, CP was associated with a lower number of packed red blood cells (median 4 vs. 7; P = 0.016) and a lower incidence of post-transplant acute kidney injury (6.9% vs. 47.1%; P = 0.003). The feasibility of CP was 95% (14/15) in patients with previous 3-vein piggyback caval anastomosis versus 48.3% (15/31) after other techniques (P = 0.003). Indirect signs of portal hypertension (PHT) before retransplantation were predictive of VVB requirement. Early and long-term outcomes were similar across the three groups (CP without VVB, CR without VVB, and VVB). Preserving the IVC in late ReLT is associated with better postoperative renal function and is facilitated by a previous 3-vein piggyback. Routine CR is not justified in late ReLT.
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Affiliation(s)
- Sophie Laroche
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France
| | - Charlotte Maulat
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France
| | - Yuki Kitano
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Nicolas Golse
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Unité INSERM 1193, Villejuif, France
| | - Daniel Azoulay
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France
| | - Antonio Sa Cunha
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Équipe Chronothérapie, Cancers et Transplantation, Université Paris Saclay, Villejuif, France
| | - Eric Vibert
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Unité INSERM 1193, Villejuif, France
| | - René Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Équipe Chronothérapie, Cancers et Transplantation, Université Paris Saclay, Villejuif, France
| | - Daniel Cherqui
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Unité INSERM 1193, Villejuif, France
| | - Marc Antoine Allard
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Saclay, Villejuif, France.,Équipe Chronothérapie, Cancers et Transplantation, Université Paris Saclay, Villejuif, France
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15
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Impact of side-to-side cavocavostomy versus traditional piggyback implantation in liver transplantation. Surgery 2020; 168:1060-1065. [DOI: 10.1016/j.surg.2020.07.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/18/2020] [Accepted: 07/12/2020] [Indexed: 02/06/2023]
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16
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Leao Filho H, de Oliveira CV, Horvat N. Other types of diffuse liver disease: is there a way to do it? Abdom Radiol (NY) 2020; 45:3425-3443. [PMID: 32306241 DOI: 10.1007/s00261-020-02530-6] [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] [Indexed: 12/17/2022]
Abstract
There are a variety of less common diffuse liver diseases that can be asymptomatic or cause severe liver dysfunction. For the majority of them, the association of clinical, laboratory, and imaging findings are needed to narrow the differential diagnosis. In this article, we will review and describe the rarer diffuse liver diseases including drug-related liver disease, inflammatory and infectious diseases, and deposition disorders such as amyloidosis, glycogen storage disease, Wilson's disease, and alpha-1 antitrypsin deficiency. Abdominal radiologists should be familiar with the imaging features of different types of diffuse liver diseases to help the multidisciplinary team involved in the treatment of these patients. The data related to some of these conditions are scarce and sometimes experimental, but we want to demonstrate to the reader the value of imaging techniques in their analysis and introduce the potential of new imaging methods.
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17
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Inchingolo R, Posa A, Mariappan M, Tibana TK, Nunes TF, Spiliopoulos S, Brountzos E. Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome: A comprehensive review. World J Gastroenterol 2020; 26:5060-5073. [PMID: 32982109 PMCID: PMC7495032 DOI: 10.3748/wjg.v26.i34.5060] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/06/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
Budd-Chiari syndrome (BCS) is a relatively rare clinical condition with a wide range of symptomatology, caused by the obstruction of the hepatic venous outflow. If left untreated, it has got an high mortality rate. Its management is based on a step-wise approach, depending on the clinical presentation, and includes different treatment from anticoagulation therapy up to Interventional Radiology techniques, such as transjugular intrahepatic portosystemic shunt (TIPS). TIPS is today considered a safe and highly effective treatment and should be recommended for BCS patients, including those awaiting orthotopic liver transplantation. In this review the pathophysiology, diagnosis and treatment options of BCS are presented, with a special focus on published data regarding the techniques and outcomes of TIPS for the treatment of BCS. Moreover, unresolved issues and future research will be discussed.
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Affiliation(s)
- Riccardo Inchingolo
- Interventional Radiology Unit, "F. Miulli" Regional Hospital, Acquaviva delle Fonti 70021, Italy
- Department of Radiology, King´s College Hospital, London SE5 9RS, United Kingdom
| | - Alessandro Posa
- Department of Radiology, Gemelli Hospital, Roma 00135, Italy
| | - Martin Mariappan
- Interventional Radiology Department, Aberdeen Royal Infirmary Hospital, Aberdeen AB25 2ZN, United Kingdom
| | - Tiago Kojun Tibana
- Interventional Radiology Department, Universidade Federal de Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Thiago Franchi Nunes
- Interventional Radiology Department, Universidade Federal de Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Stavros Spiliopoulos
- 2nd Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Chaidari Athens GR 12461, Greece
| | - Elias Brountzos
- 2nd Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Chaidari Athens GR 12461, Greece
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18
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Massarollo PCB, Coelho FF, Brescia MDG, Sandoli Baía CE, Lallée MP, Dias de Almeida M, Salzedas-Netto AA, Coppini AZ, Massarollo DB, Mies S. Long-term Outcome of a Modified Piggyback Liver Transplantation Technique Using the Recipient's Right and Middle Hepatic Veins. Transplant Proc 2020; 52:1308-1311. [PMID: 32247596 DOI: 10.1016/j.transproceed.2020.02.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/07/2020] [Indexed: 11/18/2022]
Abstract
In early piggyback liver transplantation (LT) descriptions, the common stump of the middle and left hepatic veins (ML) was used for upper caval anastomosis. In this variant, stenosis or kinking of graft venous outflow path was frequent. Over time, most authors adopted the use of the recipient's right, middle, and left hepatic veins (RML) or a side-to-side anastomosis (SS) between the graft's and recipient's inferior vena cava (IVC). Nonetheless, partial IVC clamping required in RML and SS can reduce IVC flow. Since 1998, we incorporated a modified piggyback procedure using the recipient's right and middle hepatic veins (RM) to simultaneously achieve better preservation of IVC flow and a wide and well-positioned anastomosis. OBJECTIVE The aim of this study is to describe the RM method and to compare this technique with other standard variants of piggyback LT. METHOD We conducted a retrospective analysis of 477 piggyback LTs classified in 4 groups: ML (n = 102); RM (n = 171); RML (n = 150); and SS (n = 54). RESULTS The incidence of venous outflow block was 3.9% (4/102) in ML, 2.3% (4/171) in RM, 0% (0/150) in RML, and 3.7% (2/54) in SS (P = .049). On Bonferroni multiple comparison analysis, no statistically significant paired difference was identified. Results showed that 1-, 3-, 5-, and 10-year patient survival was 76%, 67%, 63%, and 51% in the ML group; 80%, 71%, 68%, and 62% in the RM group; 77%, 75%, 70%, and 64% in the RML group; and 76%, 76%, 76%, and 70% in the SS group, respectively (P = .193). CONCLUSION The RM modified piggyback LT technique is feasible and safe.
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Affiliation(s)
| | | | | | | | - Margareth Pauli Lallée
- LIM-02, Department of Surgery, University of São Paulo Medical School, São Paulo, Brazil; Hospital de Transplantes Euryclides de Jesus Zerbini, São Paulo, Brazil
| | | | - Alcides Augusto Salzedas-Netto
- Transplant Service, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil; Department of Surgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Adriana Zuolo Coppini
- Transplant Service, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Daniel Braga Massarollo
- Transplant Service, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Sérgio Mies
- LIM-02, Department of Surgery, University of São Paulo Medical School, São Paulo, Brazil
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19
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Further to the Right: Piggyback Anastomosis on the Right Hepatic Vein Facilitates the Implantation of Small Liver Grafts (the One-vein Technique). Ann Surg 2020; 269:e60-e62. [PMID: 30985358 DOI: 10.1097/sla.0000000000003039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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20
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Liver Transplantation. THE CRITICALLY ILL CIRRHOTIC PATIENT 2020. [PMCID: PMC7122092 DOI: 10.1007/978-3-030-24490-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The field of liver transplantation has changed since the MELD scoring system became the most widely used donor allocation tool. Due to the MELD-based allocation system, sicker patients with higher MELD scores are being transplanted. Persistent organ donor shortages remain a challenging issue, and as a result, the wait-list mortality is a persistent problem for most of the regions. This chapter focuses on deceased donor and live donor liver transplantation in patients with complications of portal hypertension. Special attention will also be placed on donor-recipient matching, perioperative management of transplant patients, and the impact of hepatic hemodynamics on transplantation.
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21
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Bernts LHP, Drenth JPH, Tjwa ETTL. Management of portal hypertension and ascites in polycystic liver disease. Liver Int 2019; 39:2024-2033. [PMID: 31505092 PMCID: PMC6899472 DOI: 10.1111/liv.14245] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/02/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022]
Abstract
Patients suffering from polycystic liver disease may develop Hepatic Venous Outflow Obstruction, Portal Vein Obstruction and/or Inferior Caval Vein Syndrome because of cystic mass effect. This can cause portal hypertension, leading to ascites, variceal haemorrhage or splenomegaly. For this review, we evaluate the evidence to provide clinical guidance for physicians faced with this complication. Diagnosis is made with imaging such as ultrasound, computed tomography or magnetic resonance imaging. Therapy includes conventional therapy with diuretics and paracentesis, and medical therapy using somatostatin analogues. Based on disease phenotype various (non-)surgical liver-volume reducing therapies, hepatic or portal venous stenting, transjugular intrahepatic portosystemic shunts and liver transplantation may be considered. Because of complicated anatomy, use of high-risk interventions and lack of empirical evidence, patients should be treated in expert centres.
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Affiliation(s)
- Lucas H. P. Bernts
- Department of Gastroenterology and HepatologyRadboud Institute for Molecular Life SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Joost P. H. Drenth
- Department of Gastroenterology and HepatologyRadboud Institute for Molecular Life SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Eric T. T. L. Tjwa
- Department of Gastroenterology and HepatologyRadboud Institute for Molecular Life SciencesRadboud University Medical CenterNijmegenThe Netherlands
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22
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Sengstaken Tube Removal under Direct Hemodynamic Monitoring after Post Transplantation Venous Occlusion. Case Rep Surg 2019; 2019:6146125. [PMID: 31559103 PMCID: PMC6735169 DOI: 10.1155/2019/6146125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 05/14/2019] [Indexed: 11/17/2022] Open
Abstract
The surgical procedure for orthotopic liver transplantation (OLT) is well standardized, and most groups use the retrohepatic caval preservation or piggyback technique to improve hemodynamic tolerance. However, when a discrepancy between the site in the right upper quadrant of the liver recipient and a small graft is present, this technique can provoke a rotation on the axis of the vena cava and cause an occlusion of the suprahepatic vein drainage. This problem can be detected intraoperatively, and several methods have been described to resolve it by placing different devices to correct the position. Early withdrawal may cause the development of clinical hepatic congestion with ascites unresponsive to medical treatment. We present three cases of OLT who developed obstruction of the venous drainage solved intraoperatively with the placement of a Sengstaken-Blakemore tube. As a novelty, prior to the withdrawal of the device, a transjugular hemodynamic study was performed to ensure the correct position of the liver with adequate venous drainage.
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23
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Shimata K, Sugawara Y, Honda M, Ikeda O, Tamura Y, Hayashida S, Ohya Y, Yamamoto H, Yamashita Y, Inomata Y, Hibi T. Efficacy of repeated balloon venoplasty for treatment of hepatic venous outflow obstruction after pediatric living-donor liver transplantation: A single-institution experience. Pediatr Transplant 2019; 23:e13522. [PMID: 31210388 DOI: 10.1111/petr.13522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/18/2019] [Accepted: 05/20/2019] [Indexed: 12/19/2022]
Abstract
HVOO is a rare complication after LT and an important cause of graft failure. Balloon venoplasty is the first-line treatment for HVOO, but the effect of repeated balloon venoplasty and stent placement for HVOO recurrence after pediatric LDLT remains unclear. Between 1998 and 2016, 147 pediatric patients underwent LDLT in our institution. Among them, the incidence of HVOO and the therapeutic strategy were retrospectively reviewed. Ten patients were diagnosed with HVOO. All the patients underwent LLS grafts. Median age at the initial endovascular intervention was 2.7 years (range, 5 months-8 years). The median interval between the LDLT and the initial interventional radiology was 2.7 months (range, 29 days-35.7 months). Four patients experienced no recurrence after a single balloon venoplasty; 6 underwent balloon venoplasty more than 3 times because of HVOO recurrence; and 2 underwent stent placement due to the failure of repeated balloon venoplasty. All patients are alive with no symptoms of HVOO. The HVOO recurrence-free period after the last intervention ranged from 20 days to 15.5 years (median, 8.9 years). Repeated balloon venoplasty may prevent unnecessary stent placement to treat recurrent HVOO after pediatric LDLT.
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Affiliation(s)
- Keita Shimata
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Yasuhiko Sugawara
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Masaki Honda
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Osamu Ikeda
- Department of Diagnostic Radiology, Kumamoto University Hospital, Kumamoto, Japan
| | - Yoshitaka Tamura
- Department of Diagnostic Radiology, Kumamoto University Hospital, Kumamoto, Japan
| | - Shintaro Hayashida
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Yuki Ohya
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Hidekazu Yamamoto
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Yasuyuki Yamashita
- Department of Diagnostic Radiology, Kumamoto University Hospital, Kumamoto, Japan
| | - Yukihiro Inomata
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Taizo Hibi
- Department of Transplantation and Pediatric Surgery, Kumamoto University Hospital, Kumamoto, Japan
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24
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Lim C, Osseis M, Tudisco A, Lahat E, Sotirov D, Salloum C, Azoulay D. Hepatic venous outflow obstruction after whole liver transplantation of large-for-size graft: versatile intra-operative management. Ann Hepatobiliary Pancreat Surg 2018; 22:321-325. [PMID: 30588522 PMCID: PMC6295374 DOI: 10.14701/ahbps.2018.22.4.321] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 07/03/2018] [Accepted: 07/10/2018] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Preservation of the native inferior vena cava using a large graft during adult whole liver transplantation is associated with a potential risk of hepatic venous outflow compression/obstruction, which may adversely affect both graft and short-term patient outcomes. Intraoperative placement of materials to restore adequate hepatic venous outflow can overcome this complication. Methods Data of patients who underwent liver transplantation between 2011 and 2016 were retrospectively reviewed. All cases of hepatic venous outflow obstruction due to large graft size managed via intraoperative intervention were analyzed. The literature was searched for studies reporting adult cases of hepatic venous outflow obstruction following whole liver transplantation managed extrahepatically. Results Three patients diagnosed with intraoperative hepatic venous outflow obstruction due to large graft size were managed via retro-hepatic placement of breast implants (2 cases) or abdominal pads (1 case). It was successfully carried out in all cases. Four studies including 15 patients were identified in the literature search. Different types of materials such as inflatable materials (Foley catheter, Blakemore balloon), surgical gloves or breast implants, were used. Conclusions Placement of inflatable materials leads to gradual deflation in the postoperative period, which might obviate the need for reoperation. Breast implants could be left in place indefinitely due to their bio-inert nature.
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Affiliation(s)
- Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Michael Osseis
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Antonella Tudisco
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Dobromir Sotirov
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France.,Université Paris-Est UPEC, Créteil, France.,INSERM, U955, Créteil, France
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Lu KT, Cheng YF, Chen TY, Tsang LC, Ou HY, Yu CY, Hsu HW, Lim WX, Tong YS, Huang TL. Efficiency of Transluminal Angioplasty of Hepatic Venous Outflow Obstruction in Pediatric Liver Transplantation. Transplant Proc 2018; 50:2715-2717. [DOI: 10.1016/j.transproceed.2018.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/26/2018] [Accepted: 04/09/2018] [Indexed: 01/10/2023]
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Abstract
Graft dysfunction of the liver allograft manifests across a spectrum in both timing posttransplantation and clinical presentation. This can range from mild transient abnormalities of liver tests to acute liver failure potentially leading to graft failure. The causes of graft dysfunction can be divided into those resulting in early and late graft dysfunction. Although nonspecific, liver biochemistry abnormalities are still the mainstay investigation used in monitoring for dysfunction. This article provides a summary of the main causes and management strategies for liver graft dysfunction in the early through late posttransplant stages.
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Affiliation(s)
- Beverley Kok
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Canada
| | - Victor Dong
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Canada
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Canada.
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Fukuda A, Sakamoto S, Sasaki K, Narumoto S, Kitajima T, Hirata Y, Hishiki T, Kasahara M. Modified triangular hepatic vein reconstruction for preventing hepatic venous outflow obstruction in pediatric living donor liver transplantation using left lateral segment grafts. Pediatr Transplant 2018; 22:e13167. [PMID: 29484815 DOI: 10.1111/petr.13167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 12/15/2022]
Abstract
HVOO can be a critical complication in pediatric LDLT. The aim of this study was to evaluate a modified triangular technique of hepatic vein reconstruction for preventing HVOO in pediatric LDLT. A total of 298 pediatric LDLTs were performed using a left lateral segment graft by 2 methods for reconstruction of the hepatic vein. In 177 recipients, slit-shaped anastomosis was indicated with partial clamp of the IVC. A total of 121 recipients subjected to the modified triangular anastomosis with total clamp of the IVC. We compared the incidence of hepatic vein anastomotic complications between these 2 methods. Nine of the 177 cases (5.3%) treated with the conventional technique were diagnosed with outflow obstruction. All 9 cases underwent hepatic vein reconstruction with the slit-shaped hepatic vein anastomosis. In contrast, there were no cases of outflow obstruction in the 121 cases treated with the modified triangular anastomosis. The modified triangular technique of hepatic vein reconstruction with total clamping of the IVC was useful for preventing HVOO in pediatric LDLT.
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Affiliation(s)
- Akinari Fukuda
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kengo Sasaki
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Soichi Narumoto
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Toshihiro Kitajima
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshihiro Hirata
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Tomoro Hishiki
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Liver Transplantation Without Venovenous Bypass: Does Surgical Approach Matter? Transplant Direct 2018; 4:e348. [PMID: 29796419 PMCID: PMC5959343 DOI: 10.1097/txd.0000000000000776] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 01/31/2018] [Indexed: 12/31/2022] Open
Abstract
Background The use of venovenous bypass in liver transplantation has declined over time. Few studies have examined the impact of surgical approach in cases performed exclusively without venovenous bypass. We hypothesized that advances in liver transplant anesthesia and perioperative care have minimized the importance of surgical approach in the modern era. Methods Deceased donor liver transplants at the University of Toronto from 2000 to 2015 were reviewed, all performed without venovenous bypass. First, an unadjusted analysis was performed comparing perioperative outcomes and graft/patient survival for 3 different liver transplant techniques (caval interposition, piggyback, side-to-side cavo-cavostomy). Second, a propensity-matched analysis was performed comparing caval interposition to caval-preserving techniques. Results One thousand two hundred thirty-three liver transplants were included in the study. On unadjusted analysis, blood loss, transfusion requirement, postoperative complications, and graft/patient survival were equivalent for the 3 different techniques. To account for possible confounding patient variables, propensity matching was performed. Analysis of the propensity-matched cohorts also demonstrated similar outcomes for caval interposition versus caval-preserving approaches. Conclusions In the modern era at centers with a multidisciplinary team, the importance of specific liver transplant technique is minimized. Full or partial cross-clamping of the inferior vena cava is feasible without the use of venovenous bypass.
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Horvat N, Marcelino ASZ, Horvat JV, Yamanari TR, Batista Araújo-Filho JDA, Panizza P, Seda-Neto J, Antunes da Fonseca E, Carnevale FC, Mendes de Oliveira Cerri L, Chapchap P, Cerri GG. Pediatric Liver Transplant: Techniques and Complications. Radiographics 2018; 37:1612-1631. [PMID: 29019744 DOI: 10.1148/rg.2017170022] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Liver transplant is considered to be the last-resort treatment approach for pediatric patients with end-stage liver disease. Despite the remarkable advance in survival rates, liver transplant remains an intricate surgery with significant morbidity and mortality. Early diagnosis of complications is crucial for patient survival but is challenging given the lack of specificity in clinical presentation. Knowledge of the liver and vascular anatomy of the donor and the recipient or recipients before surgery is also important to avoid complications. In this framework, radiologists play a pivotal role on the multidisciplinary team in both pre- and postoperative scenarios by providing a road map to guide the surgery and by assisting in diagnosis of complications. The most common complications after liver transplant are (a) vascular, including the hepatic artery, portal vein, hepatic veins, and inferior vena cava; (b) biliary; (c) parenchymal; (d) perihepatic; and (e) neoplastic. The authors review surgical techniques, the role of each imaging modality, normal posttransplant imaging features, types of complications after liver transplant, and information required in the radiology report that is critical to patient care. They present an algorithm for an imaging approach for pediatric patients after liver transplant and describe key points that should be included in radiologic reports in the pre- and postoperative settings. Online supplemental material is available for this article. ©RSNA, 2017.
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Affiliation(s)
- Natally Horvat
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Antonio Sergio Zafred Marcelino
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Joao Vicente Horvat
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Tássia Regina Yamanari
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Jose de Arimateia Batista Araújo-Filho
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Pedro Panizza
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Joao Seda-Neto
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Eduardo Antunes da Fonseca
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Francisco Cesar Carnevale
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Luciana Mendes de Oliveira Cerri
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Paulo Chapchap
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
| | - Giovanni Guido Cerri
- From the Departments of Radiology (N.H., A.S.Z.M., T.R.Y., J.d.A.B.A.F., P.P., L.M.d.O.C., G.G.C.), Surgery (J.S.N., E.A.d.F., P.C.), and Interventional Radiology (F.C.C.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 91, São Paulo, SP 01308-050, Brazil; and Department of Radiology, University of São Paulo, São Paulo, Brazil (N.H., J.V.H., J.d.A.B.A.F., F.C.C., G.G.C.)
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Ye Q, Zeng C, Wang Y, Fang Z, Hu X, Xiong Y, Li L. Risk Factors for Hepatic Venous Outflow Obstruction in Piggyback Liver Transplantation: The Role of Recipient's Pattern of Hepatic Veins Drainage into the Inferior Vena Cava. Ann Transplant 2017; 22:303-308. [PMID: 28522795 PMCID: PMC6248070 DOI: 10.12659/aot.902753] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background The recipient’s pattern of hepatic veins (HVs) drainage into the inferior vena cava (IVC) (drainage pattern, for short) may influence outflow reconstruction and thus hepatic venous outflow obstruction (HVOO) in piggyback liver transplantation (PBLT). However, no previous study has investigated this association. Material/Methods A retrospective analysis of 202 PBLT (2000–2016) was conducted. Based on drainage patterns, the patients were divided into Group A (common trunk of left and middle HVs), Group B (common trunk of right and middle HVs), and Group C (common trunk of 3 HVs). Patients’ demographic and surgical data were compared within the 3 groups, and risk factors for HVOO were tested using a multiple logistic regression model. Results A chi-square test revealed a significantly higher HVOO incidence in Group 1 compared with the other groups (23.5% vs. 9.6% vs. 7.1%, p=0.047). The demographics and surgical data except angle∠AOB between the reconstructed outflow and IVC in cross-section of 3D image (∠AOB), ratio of the length of reconstructed outflow and ∠AOB (LRO/∠AOB ratio), and types of HV ligation did not differ significantly within the 3 groups. ∠AOB and LRO/∠AOB ratio were used to assess the level of anastomosis twisting and compression, respectively. Among the 3 groups, the largest ∠AOB and highest LRO/∠AOB ratio were observed in Group A and B, respectively. In addition, multivariate analysis indicated that the ∠AOB (OR=1.016, 95%CI: 1.006–1.027) and LRO/∠AOB ratio (OR=2.254, 95% CI: 1.041–5.519) were risk factors for HVOO. Conclusions This study demonstrated that drainage patterns were associated with HVOO. The best choice for outflow reconstruction is Group C. The patients in Group A and B were likely to develop HVOO due to anastomosis twisting and compression, respectively.
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Affiliation(s)
- Qifa Ye
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland).,The 3rd Xiangya Hospital of Central South University, Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, Hunan, China (mainland)
| | - Cheng Zeng
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Yanfeng Wang
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Zhehong Fang
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Xiaoyan Hu
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Yan Xiong
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
| | - Ling Li
- Wuhan University, Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan, Hubei, China (mainland)
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Treatment of Inferior Vena Cava Obstruction Following Pediatric Liver Transplantation: Novel Use of a Customized Endovascular Stent. J Pediatr 2017; 180:256-260. [PMID: 27793336 DOI: 10.1016/j.jpeds.2016.09.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/18/2016] [Accepted: 09/19/2016] [Indexed: 12/16/2022]
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Chu HH, Yi NJ, Kim HC, Lee KW, Suh KS, Jae HJ, Chung JW. Longterm outcomes of stent placement for hepatic venous outflow obstruction in adult liver transplantation recipients. Liver Transpl 2016; 22:1554-1561. [PMID: 27516340 DOI: 10.1002/lt.24598] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/23/2016] [Indexed: 12/11/2022]
Abstract
The purpose of this study was to evaluate the longterm outcomes of stent placement for a hepatic venous outflow obstruction in adult liver transplantation recipients. From June 2002 to March 2014, 23 patients were confirmed to have a hepatic venous outflow obstruction after liver transplantation (18 of 789 living donors [2.3%] and 5 of 449 deceased donors [1.1%]) at our institute. Among these patients, stent placement was needed for 16 stenotic lesions in 15 patients (12 males, 3 females; mean age, 51.7 years). The parameters that were documented retrospectively were technical success, clinical success, complications, recurrence, and the patency of the stent. The technical success rate was 100% (16/16). Clinical success was achieved in 11 of the 15 patients (73.3%). A major complication occurred in only 1 patient-a hepatic vein laceration during the navigation of the occluded segment. The median follow-up period was 33.5 months (range, 0.5-129.3 months), and the overall 1-, 3-, and 5-year primary patency rates of the stent were all 93.8%. One case of occlusion of the stent without clinical signs and symptoms was observed 5 days after the initial procedure. In this patient, the stent was recanalized by balloon angioplasty and showed patent lumen for 48 months of the subsequent follow-up period. In conclusion, stent placement is a safe and effective treatment modality with favorable longterm outcomes to treat hepatic venous outflow obstruction in adult liver transplantation recipients. Liver Transplantation 22 1554-1561 2016 AASLD.
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Affiliation(s)
- Hee Ho Chu
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hyo-Cheol Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea.
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hwan Jun Jae
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jin Wook Chung
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
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Panaro F, Boisset G, Chanques G, Guiu B, Herrero A, Bouyabrine H, Pageaux GP, Boudjema K, Navarro F. Vena cava encirclement predicts difficult native hepatectomy. Liver Transpl 2016; 22:906-13. [PMID: 27149437 DOI: 10.1002/lt.24478] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/06/2016] [Indexed: 12/14/2022]
Abstract
Recipient hepatectomy is a challenging liver transplantation (LT) procedure that has life-threatening complications. The current predictive mortality clinic-biological scores (Child/Model for End-Stage Liver Disease [MELD]) do not take into consideration the recipient's liver anatomy. The aim of this study was to evaluate the impact of the dorsal sector anatomy of a cirrhotic liver on the morbidity/mortality rates of hepatectomy. A multicenter retrospective study (clinic-biological and morphologic) was performed from 2013 to 2014. The degree of encirclement of the inferior vena cava (IVC) by the dorsal sector of the liver was measured. The study population included 320 patients. Seventy-four (23%) patients had complete IVC encirclement. A correlation (P = 0.01) has been reported between the existence of a circular dorsal sector and the number of transfusions during LT (4 packed red blood cell [PRBC] transfusions in the group without IVC versus 7 PRBC transfusions in the other group). The existence of such anatomy increases the relative risk of early reoperation for IVC bleeding by 31% (P = 0.05). There is a correlation between alcoholic cirrhosis and dorsal-sector hypertrophy (126 cc versus 147.5 cc; P = 0.05). Concerning surgical time, we found no significant between-group differences. Compared to the severity of cirrhosis, an inverse correlation was observed between the MELD and Child scores and the dorsal sector hypertrophy (P < 0.001). No significant difference in terms of transfusion was found between the temporary portocaval shunt group (n = 168) and the other group (n = 152). The presence of a circular sector is associated with an increased risk of hemorrhage during hepatectomy, as well as an immediate postoperative risk of reoperation. Liver Transplantation 22 906-913 2016 AASLD.
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Affiliation(s)
- Fabrizio Panaro
- Departments of General Surgery, Division of Transplantation, College of Medicine, University of Montpellier, Montpellier, France
| | - Gildas Boisset
- Departments of General Surgery, Division of Transplantation, College of Medicine, University of Montpellier, Montpellier, France
| | - Gérald Chanques
- Departments of Anesthesiology and Critical Care Medicine, University of Montpellier, Montpellier, France
| | - Boris Guiu
- Departments of Radiology, Faculty of Medicine, Saint Eloi Hospital, University of Montpellier, Montpellier, France
| | - Astrid Herrero
- Departments of General Surgery, Division of Transplantation, College of Medicine, University of Montpellier, Montpellier, France
| | - Hassan Bouyabrine
- Departments of General Surgery, Division of Transplantation, College of Medicine, University of Montpellier, Montpellier, France
| | - Georges Philippe Pageaux
- Departments of General Surgery, Division of Transplantation, College of Medicine, University of Montpellier, Montpellier, France
| | - Karim Boudjema
- Service de Chirurgie Hépatobiliaire et Digestive, Hôpital Pontchaillou, Centre Hospitalier, Rennes, France.,INSERM, UMR991, Foie, Métabolisme et Cancer, Université de Rennes 1, Rennes, France
| | - Francis Navarro
- Departments of General Surgery, Division of Transplantation, College of Medicine, University of Montpellier, Montpellier, France
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Liver transplantation of a graft with a left hepatic vein draining directly into the right atrium. J Visc Surg 2016; 153:315-6. [PMID: 27318586 DOI: 10.1016/j.jviscsurg.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Karim S, Lucas V, Verma A, Girgrah N, Ramee S, Castriota F, Micari A, Roscitano G, Spinelli F, Gafoor S, Haseeb A, Khan A, Franke J, Matic P, Reinartz M, Bertog S, Vaskelyte L, Hofmann I, Sievert H. How should I treat Budd-Chiari syndrome after liver transplantation with inferior vena cava occlusion? EUROINTERVENTION 2016; 12:124-8. [PMID: 27173874 DOI: 10.4244/eijv12i1a22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Saima Karim
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
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Ingraham CR, Montenovo M. Interventional and Surgical Techniques in Solid Organ Transplantation. Radiol Clin North Am 2016; 54:267-80. [DOI: 10.1016/j.rcl.2015.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Ibáñez V, Montalvá E, Vila JJ, López-Andújar R. Surgical anterior cavoplasty for managing a case of early acute outflow obstruction after liver transplantation. Pediatr Transplant 2016; 20:151-4. [PMID: 26566858 DOI: 10.1111/petr.12629] [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] [Accepted: 10/01/2015] [Indexed: 12/01/2022]
Abstract
HVOO following liver transplantation is rarely treated surgically because it tends to debut subacutely. However, acute HVOO is a surgical emergency that compromises the viability of the graft. We report a case of HVOO diagnosed intra-operatively during surgical revision for a suspected arterial thrombosis in a 10-month-old male recipient of a second graft (segments II-III) for familial intrahepatic cholestasis. HVOO was related to a stenosis at the first transplant hepato-caval anastomosis, left in place to obtain longer venous cuffs for retransplantation. An anterior cavoplasty was necessary to resolve the issue. The new anastomosis was created under total vascular exclusion after gaining control of the supradiaphragmatic vena cava, because the inferior vena cava was unsuitable for further surgery. This approach (normally used as a means to avoid sternotomy in patients with hepatic or renal tumours associated with venous thrombosis) allows adequate vascular control and, in selected cases, offers a surgical alternative for treating HVOO.
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Affiliation(s)
- Vicente Ibáñez
- Liver Transplant Unit, La Fe University and Politecnic Hospital, Valencia, Spain
| | - Eva Montalvá
- Liver Transplant Unit, La Fe University and Politecnic Hospital, Valencia, Spain
| | - Juan J Vila
- Liver Transplant Unit, La Fe University and Politecnic Hospital, Valencia, Spain
| | - Rafael López-Andújar
- Liver Transplant Unit, La Fe University and Politecnic Hospital, Valencia, Spain
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Fujimori M, Yamakado K, Takaki H, Nakatsuka A, Uraki J, Yamanaka T, Hasegawa T, Sugino Y, Nakajima K, Matsushita N, Mizuno S, Sakuma H, Isaji S. Long-Term Results of Stent Placement in Patients with Outflow Block After Living-Donor-Liver Transplantation. Cardiovasc Intervent Radiol 2015; 39:566-74. [DOI: 10.1007/s00270-015-1210-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 09/12/2015] [Indexed: 12/14/2022]
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De la Serna S, Llado L, Ramos E, Fabregat J, Baliellas C, Busquets J, Secanella L, Pelaez N, Torras J, Rafecas A. Technical options for outflow reconstruction in domino liver transplantation: A single European center experience. Liver Transpl 2015; 21:1051-5. [PMID: 25857709 DOI: 10.1002/lt.24143] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 03/15/2015] [Accepted: 03/30/2015] [Indexed: 02/07/2023]
Abstract
Venous outflow is critical to the success of liver transplantation (LT). In domino liver transplantation (DLT), the venous cuffs should be shared between the donor and the recipient, and the length can be compromised. The aim of this study was to describe and compare the technical options for outflow reconstruction used at our institution. This was a retrospective analysis of 39 consecutive DLT recipients between January 1997 and May 2013. Twenty-seven men and 12 women (mean age, 61.8 ± 4.3 years) underwent LT and consented to receive a liver from a donor with familial amyloid polyneuropathy (FAP). The main indications were hepatocellular carcinoma and hepatitis C virus cirrhosis. All recipients underwent transplantation by a piggyback technique. Liver procurement in the FAP donors was performed with the classic technique in 22 patients and with the piggyback technique in the last 17. In these latter cases, for vascular outflow reconstruction, a cadaveric venous graft was interposed between the hepatic vein (HV) stump of the FAP liver and the recipient HV in 11 cases (28%). Since 2011, we have employed arterial grafts to be interposed between the vessels stumps: a tailored arterial graft in 5 patients and an aortic graft in 1 case. There was no postoperative mortality. Arterial and portal complications presented in 2 (5.1) and 4 patients (10.3), respectively. Postoperative outflow complications (post-LT subacute Budd-Chiari syndrome) occurred in 4 patients, and all of them had received a venous interposed graft for reconstruction. The incidence of outflow complications tended to be higher among patients with venous grafts than those with arterial graft interposition. Overall patient survival at 1, 3, 5, and 10 years was 97%, 79%, respectively. Arterial grafts constitute a feasible and safe option for vascular outflow reconstruction in DLT because they are associated with a relatively low incidence of complications. The recently proposed Bellvitge arterial graft technique should be added to the current range of available surgical modalities.
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Affiliation(s)
- Sofía De la Serna
- Liver Transplantation Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | - Laura Llado
- Liver Transplantation Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | - Emilio Ramos
- Liver Transplantation Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | - Joan Fabregat
- Liver Transplantation Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | - Carme Baliellas
- Liver Transplantation Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | - Juli Busquets
- Liver Transplantation Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | - Lluis Secanella
- Liver Transplantation Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | - Nuria Pelaez
- Liver Transplantation Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | - Jaume Torras
- Liver Transplantation Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | - Antoni Rafecas
- Liver Transplantation Unit, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
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Sarwar A, Ahn E, Brennan I, Brook OR, Faintuch S, Malik R, Khwaja K, Ahmed M. Utility of liver biopsy in predicting clinical outcomes after percutaneous angioplasty for hepatic venous obstruction in liver transplant patients. World J Hepatol 2015; 7:1884-1893. [PMID: 26207170 PMCID: PMC4506946 DOI: 10.4254/wjh.v7.i14.1884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 06/16/2015] [Accepted: 07/14/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine utility of transplant liver biopsy in evaluating efficacy of percutaneous transluminal angioplasty (PTA) for hepatic venous obstruction (HVOO).
METHODS: Adult liver transplant patients treated with PTA for HVOO (2003-2013) at a single institution were reviewed for pre/post-PTA imaging findings, manometry (gradient with right atrium), presence of HVOO on pre-PTA and post-PTA early and late biopsy (EB and LB, < or > 60 d after PTA), and clinical outcome, defined as good (no clinical issues, non-HVOO-related death) or poor (surgical correction, recurrent HVOO, or HVOO-related death).
RESULTS: Fifteen patients meeting inclusion criteria underwent 21 PTA, 658 ± 1293 d after transplant. In procedures with pre-PTA biopsy (n = 19), no difference was seen between pre-PTA gradient in 13/19 procedures with HVOO on biopsy and 6/19 procedures without HVOO (8 ± 2.4 mmHg vs 6.8 ± 4.3 mmHg; P = 0.35). Post-PTA, 10/21 livers had EB (29 ± 21 d) and 9/21 livers had LB (153 ± 81 d). On clinical follow-up (392 ± 773 d), HVOO on LB resulted in poor outcomes and absence of HVOO on LB resulted good outcomes. Patients with HVOO on EB (3/7 good, 4/7 poor) and no HVOO on EB (2/3 good, 1/3 poor) had mixed outcomes.
CONCLUSION: Negative liver biopsy greater than 60 d after PTA accurately identifies patients with good clinical outcomes.
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Khorsandi SE, Athale A, Vilca-Melendez H, Jassem W, Prachalias A, Srinivasan P, Rela M, Heaton N. Presentation, diagnosis, and management of early hepatic venous outflow complications in whole cadaveric liver transplant. Liver Transpl 2015; 21:914-21. [PMID: 25907399 DOI: 10.1002/lt.24154] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/30/2015] [Accepted: 04/11/2015] [Indexed: 02/07/2023]
Abstract
Early hepatic venous outflow obstruction (HVOO) can be a devastating complication leading to graft loss after liver transplantation (LT). A retrospective study on 777 adult LT recipients over a 5-year period (August 2007 to August 2012) was undertaken to determine the incidence of early HVOO presenting within 3 months of transplant, its clinical features and management, and potential technical risk factors related to the implanting technique. Cases of early HVOO were screened for by identifying recipients with problematic ascites within 3 months of transplant. Definitive diagnosis for HVOO was based on a wedge pressure of >12 mm Hg. Considering only whole livers, the incidence of early problematic ascites was 3% (20/695) of which more than one-third (35%, 7/20) were then confirmed to have HVOO. Overall, the incidence of early HVOO was 1% (7/695). Two hepatic veins (HVs) with extension piggybacks (PBs; n = 423) were the dominant implanting technique in the time period of study rather than the 3 HV PB (n = 182) and caval replacement techniques (n = 82). Considering the implantation technique, all cases of HVOO occurred after 2 HVs when extension PBs had been used with an incidence of 1.7% (7/423). Institutionally, early HVOO was mainly managed surgically by either cavoplasty within a month of transplant (n = 4) or retransplant (n = 1), and the remainder (n = 2) were medically managed with diuretics. In conclusion, early HVOO is rare, and there is no evidence from this study that a given implantation technique is at a higher risk of developing HVOO (2 HV with extension versus 3 HV and caval replacement; P = 0.11). However, early revisional surgery for HVOO can preserve graft function with retransplantation being reserved for when surgical cavoplasty or radiological stenting is technically not possible.
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Affiliation(s)
| | - Anuja Athale
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | | | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Andreas Prachalias
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Parthi Srinivasan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Mohamed Rela
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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Brescia MDG, Massarollo PCB, Imakuma ES, Mies S. Prospective Randomized Trial Comparing Hepatic Venous Outflow and Renal Function after Conventional versus Piggyback Liver Transplantation. PLoS One 2015; 10:e0129923. [PMID: 26115520 PMCID: PMC4482688 DOI: 10.1371/journal.pone.0129923] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 05/11/2015] [Indexed: 12/27/2022] Open
Abstract
Background This randomized prospective clinical trial compared the hepatic venous outflow drainage and renal function after conventional with venovenous bypass (n = 15) or piggyback (n = 17) liver transplantation. Methods Free hepatic vein pressure (FHVP) and central venous pressure (CVP) measurements were performed after graft reperfusion. Postoperative serum creatinine (Cr) was measured daily on the first week and on the 14th, 21st and 28th postoperative days (PO). The prevalence of acute renal failure (ARF) up to the 28th PO was analyzed by RIFLE-AKIN criteria. A Generalized Estimating Equation (GEE) approach was used for comparison of longitudinal measurements of renal function. Results FHVP-CVP gradient > 3 mm Hg was observed in 26.7% (4/15) of the patients in the conventional group and in 17.6% (3/17) in the piggyback group (p = 0.68). Median FHVP-CVP gradient was 2 mm Hg (0–8 mmHg) vs. 3 mm Hg (0–7 mm Hg) in conventional and piggyback groups, respectively (p = 0.73). There is no statistically significant difference between the conventional (1/15) and the piggyback (2/17) groups regarding massive ascites development (p = 1.00). GEE estimated marginal mean for Cr was significantly higher in conventional than in piggyback group (2.14 ± 0.26 vs. 1.47 ± 0.15 mg/dL; p = 0.02). The conventional method presented a higher prevalence of severe ARF during the first 28 PO days (OR = 3.207; 95% CI, 1.010 to 10.179; p = 0.048). Conclusion Patients submitted to liver transplantation using conventional or piggyback methods present similar results regarding venous outflow drainage of the graft. Conventional with venovenous bypass technique significantly increases the harm of postoperative renal dysfunction. Trial Registration ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT01707810
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Affiliation(s)
- Marília D’Elboux Guimarães Brescia
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- * E-mail:
| | - Paulo Celso Bosco Massarollo
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ernesto Sasaki Imakuma
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Sérgio Mies
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Beal EW, Bennett SC, Whitson BA, Elkhammas EA, Henry ML, Black SM. Caval reconstruction techniques in orthotopic liver transplantation. World J Surg Proced 2015; 5:41-57. [DOI: 10.5412/wjsp.v5.i1.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/28/2015] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
There are several caval reconstruction techniques currently in use for orthotopic liver transplantation. These include caval replacement or the conventional technique, performed with or without venovenous bypass, piggyback technique with anastomosis with two or three hepatic veins with or without cavotomy and modifications of the piggyback technique including end-to-side and side-to-side cavocaval anastomosis. There are few randomized controlled trials comparing the use of these techniques and our knowledge of their comparability is based on a few multi- and many single-center retrospective and prospective reviews. Although there are advantages and disadvantages for each technique, it is advisable that the surgeon perform the technique with which they have the most the experience and at which they are the most skilled as excellent outcomes can be obtained with any of the caval reconstruction options discussed.
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Wahab MA, Shehta A, Hamed H, Elshobary M, Salah T, Sultan AM, Fathy O, Elghawalby A, Yassen A, Shiha U. Hepatic venous outflow obstruction after living donor liver transplantation managed with ectopic placement of a foley catheter: A case report. Int J Surg Case Rep 2015; 10:65-8. [PMID: 25805611 PMCID: PMC4429842 DOI: 10.1016/j.ijscr.2015.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/08/2015] [Accepted: 03/09/2015] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The early hepatic venous outflow obstruction (HVOO) is a rare but serious complication after liver transplantation, which may result in graft loss. We report a case of early HVOO after living donor liver transplantation, which was managed by ectopic placement of foley catheter. PRESENTATION A 51 years old male patient with end stage liver disease received a right hemi-liver graft. On the first postoperative day the patient developed impairment of the liver functions. Doppler ultrasound (US) showed absence of blood flow in the right hepatic vein without thrombosis. The decision was to re-explore the patient, which showed torsion of the graft upward and to the right side causing HVOO. This was managed by ectopic placement of a foley catheter between the graft and the diaphragm and the chest wall. Gradual deflation of the catheter was gradually done guided by Doppler US and the patient was discharged without complications. DISCUSSION Mechanical HVOO results from kinking or twisting of the venous anastomosis due to anatomical mismatch between the graft and the recipient abdomen. It should be managed surgically by repositioning of the graft or redo of venous anastomosis. Several ideas had been suggested for repositioning and fixation of the graft by the use of Sengstaken-Blakemore tubes, tissue expanders, and surgical glove expander. CONCLUSION We report the use of foley catheter to temporary fix the graft and correct the HVOO. It is a simple and safe way, and could be easily monitored and removed under Doppler US without any complications.
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Affiliation(s)
- Mohamed Abdel Wahab
- Liver Transplantation Unit, Gatroenterology Surgical Center, College of Medicine, Mansoura University, Egypt
| | - Ahmed Shehta
- Liver Transplantation Unit, Gatroenterology Surgical Center, College of Medicine, Mansoura University, Egypt.
| | - Hosam Hamed
- Liver Transplantation Unit, Gatroenterology Surgical Center, College of Medicine, Mansoura University, Egypt
| | - Mohamed Elshobary
- Liver Transplantation Unit, Gatroenterology Surgical Center, College of Medicine, Mansoura University, Egypt
| | - Tarek Salah
- Liver Transplantation Unit, Gatroenterology Surgical Center, College of Medicine, Mansoura University, Egypt
| | - Ahmed Mohamed Sultan
- Liver Transplantation Unit, Gatroenterology Surgical Center, College of Medicine, Mansoura University, Egypt
| | - Omar Fathy
- Liver Transplantation Unit, Gatroenterology Surgical Center, College of Medicine, Mansoura University, Egypt
| | - Ahmed Elghawalby
- Liver Transplantation Unit, Gatroenterology Surgical Center, College of Medicine, Mansoura University, Egypt
| | - Amr Yassen
- Liver Transplantation Unit, Gatroenterology Surgical Center, College of Medicine, Mansoura University, Egypt
| | - Usama Shiha
- Radiology Department, Gatroenterology Surgical Center, Mansoura University, Egypt
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Hepatic venous outflow obstruction after transplantation: Outcomes for treatment with self-expanding stents. RADIOLOGIA 2015. [DOI: 10.1016/j.rxeng.2013.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Houben P, Büchler MW, Schemmer P. Use of an electrothermal bipolar vessel sealing device during recipient hepatectomy for liver transplantation. J Am Coll Surg 2014; 219:e59-63. [PMID: 25260682 DOI: 10.1016/j.jamcollsurg.2014.07.941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 07/03/2014] [Accepted: 07/30/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Philipp Houben
- Department of General and Transplant Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General and Transplant Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Peter Schemmer
- Department of General and Transplant Surgery, University Hospital of Heidelberg, Heidelberg, Germany.
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Emond JC, de Ville de Goyet J. Hepatic venous reconstruction as the stake of the liver: technical note and thoughts. Pediatr Transplant 2014; 18:420-2. [PMID: 25041329 DOI: 10.1111/petr.12292] [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] [Accepted: 04/24/2014] [Indexed: 12/12/2022]
Affiliation(s)
- Jean C Emond
- Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
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Schmitz V, Schoening W, Jelkmann I, Globke B, Pascher A, Bahra M, Neuhaus P, Puhl G. Different cava reconstruction techniques in liver transplantation: piggyback versus cava resection. Hepatobiliary Pancreat Dis Int 2014; 13:242-9. [PMID: 24919606 DOI: 10.1016/s1499-3872(14)60250-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Originally, cava reconstruction (CR) in liver transplantation meant complete resection and reinsertion of the donor cava. Alternatively, preservation of the recipients inferior vena cava (IVC) with side-to-side anastomosis (known as "piggyback") can be performed. Here, partial clamping maintains blood flow of the IVC, which may improve cardiovascular stability, reduce blood loss and stabilize kidney function. The aim of this study was to compare both techniques with particular focus on kidney function. METHODS A series of 414 patients who had had adult liver transplantations (2006-2009) were included. Among them, 176 (42.5%) patients had piggyback and 238 had classical CR operation, 112 (27.1%) of the patients underwent CR accompanied with veno-venous bypass (CR-B) and 126 (30.4%) without a bypass. The choice of either technique was based on the surgeons' individual preference. Kidney function [serum creatinine, calculated glomerular filtration rate (GFR), RIFLE stages] was assessed over 14 days. RESULTS Lab-MELD scores were significantly higher in CR-B (22.5+/-11.0) than in CR (17.3+/-9.0) and piggyback (18.8+/-10.0) (P=0.008). Unexpectedly, the incidences of arterial stenoses (P=0.045) and biliary leaks (P=0.042) were significantly increased in piggyback. Preoperative serum creatinine levels were the highest in CR-B [1.45+/-1.17 vs 1.25+/-0.85 (piggyback) and 1.13+/-0.60 mg/dL (CR); P=0.033]. Although a worsening of postoperative kidney function was observed among all groups, this was most pronounced in CR-B [creatinine day 14: 1.67+/-1.40 vs 1.35+/-0.96 (piggyback) and 1.45+/-1.03 mg/dL (CR); P=0.102]. Accordingly, the proportion of patients displaying RIFLE stages ≥2 was the highest in CR/CR-B (26%/19%) when compared to piggyback (18%). CONCLUSIONS Piggyback revealed a shorter warm ischemic time, a reduced blood loss, and a decreased risk of acute kidney failure. Thus, piggyback is a useful technique, which should be applied in standard procedures. When piggyback is unfeasible, cava replacement, which displayed a lower incidence of vascular and biliary complications in our study, remains as a safe alternative.
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Affiliation(s)
- Volker Schmitz
- Department of General, Visceral and Transplantation Surgery, Charite, Campus Virchow, Berlin, Germany.
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Girometti R, Como G, Bazzocchi M, Zuiani C. Post-operative imaging in liver transplantation: State-of-the-art and future perspectives. World J Gastroenterol 2014; 20:6180-6200. [PMID: 24876739 PMCID: PMC4033456 DOI: 10.3748/wjg.v20.i20.6180] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Orthotopic liver transplantation (OLT) represents a major treatment for end-stage chronic liver disease, as well as selected cases of hepatocellular carcinoma and acute liver failure. The ever-increasing development of imaging modalities significantly contributed, over the last decades, to the management of recipients both in the pre-operative and post-operative period, thus impacting on graft and patients survival. When properly used, imaging modalities such as ultrasound, multidetector computed tomography, magnetic resonance imaging (MRI) and procedures of direct cholangiography are capable to provide rapid and reliable recognition and treatment of vascular and biliary complications occurring after OLT. Less defined is the role for imaging in assessing primary graft dysfunction (including rejection) or chronic allograft disease after OLT, e.g., hepatitis C virus (HCV) recurrence. This paper: (1) describes specific characteristic of the above imaging modalities and the rationale for their use in clinical practice; (2) illustrates main imaging findings related to post-OLT complications in adult patients; and (3) reviews future perspectives emerging in the surveillance of recipients with HCV recurrence, with special emphasis on MRI.
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