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Shahbazov R, Azari F, Xu T, Saracino G, Maluf D, Pelletier SJ. Effects of Initial Hepatic Artery Followed by Portal Reperfusion Technique on Deceased Donor Liver Transplant Outcomes. EXP CLIN TRANSPLANT 2021; 19:671-675. [PMID: 33928876 DOI: 10.6002/ect.2020.0555] [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 Although initial portal vein reperfusion of a liver allograft is nearly standardized, limited data suggest initial hepatic artery reperfusion may improve hemodynamics and posttransplant outcomes. MATERIALS AND METHODS We retrospectively reviewed orthotopic liver transplants performed between January 2013 and February 2018. Parameters of liver recipients with initial hepatic artery reperfusion were compared with those with initial portal vein reperfusion. RESULTS Of 204 recipients, 53 (26%) were initially perfused from the hepatic artery and 151 (74%) were initially perfused from the portal vein. Demographics between groups did not differ. There were no significant differences in the incidence of acute rejection between recipients with initial hepatic artery reperfusion versus portal vein reperfusion at 3 months and 1 year (1.9% vs 7.9% and 7.5% vs 10.6%; not significant), hepatic artery thrombosis (1.9% vs 4.0% and 1.9% vs 7.3%; not significant), biliary leakage (7.5% vs 4.0% and 9.4 vs 6.6; not significant), biliary strictures (7.5% vs 5.3% and 11.3% vs 7.9%; not significant), or portal or hepatic venous thrombosis/stenosis (5.7% vs 5.3% and 7.5% vs 7.9%; not significant). Furthermore, recipients with initial hepatic artery reperfusion and portal vein reperfusion were both hospitalized for a median of 8.5 days (interquartile range, 6.5-15.5 vs 7.0-14.0 days, respectively), and both groups were in the intensive care unit for a median of 3 days (interquartile range, 2-7 vs 2-4 days, respectively). Initial hepatic artery reperfusion was associated with significantly less intraoperative packet red blood cell transfusion (median, 11.9 U [interquartile range, 11.1-13.1 U] vs 15.5 U [interquartile range, 12.9-17.9 U]; P < .001). The 2 groups did not differ in terms of patient and graft survival. CONCLUSIONS Initial reperfusion of liver allografts with arterial, rather than portal, blood has benefits to hemodynamic stability, did not have deleterious effects on outcomes, and resulted in less intraoperative blood utilization.
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Affiliation(s)
- Rauf Shahbazov
- From the Department of Surgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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Marants R, Qirjazi E, Lai KB, Szeto CC, Li PKT, Li F, Lee TY, McIntyre CW. Exploring the Link Between Hepatic Perfusion and Endotoxemia in Hemodialysis. Kidney Int Rep 2021; 6:1336-1345. [PMID: 34013112 PMCID: PMC8116762 DOI: 10.1016/j.ekir.2021.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 01/18/2023] Open
Abstract
Introduction The liver receives gut-derived endotoxin via the portal vein, clearing it before it enters systemic circulation. Hemodialysis negatively impacts the perfusion and function of multiple organs systems. Dialysate cooling reduces hemodialysis-induced circulatory stress and protects organs from ischemic injury. This study examined how hemodialysis disrupts liver hemodynamics and function, its effect on endotoxemia, and the potential protective effect of dialysate cooling. Methods Fifteen patients were randomized to receive either standard (36.5°C dialysate temperature) or cooled (35.0°C) hemodialysis first in a two-visit crossover trial. We applied computed tomography (CT) liver perfusion imaging to patients before, 3 hours into and after each hemodialysis session. We measured hepatic perfusion and perfusion heterogeneity. Hepatic function was measured by indocyanine green (ICG) clearance. Endotoxin levels in blood throughout dialysis were also measured. Results During hemodialysis, overall liver perfusion did not significantly change, but portal vein perfusion trended towards increasing (P = 0.14) and perfusion heterogeneity significantly increased (P = 0.038). In addition, ICG clearance decreased significantly during hemodialysis (P = 0.016), and endotoxin levels trended towards increasing during hemodialysis (P = 0.15) and increased significantly after hemodialysis (P = 0.037). Applying dialysate cooling trended towards abrogating these changes but did not reach statistical significance compared to standard hemodialysis. Conclusion Hemodialysis redistributes liver perfusion, attenuates hepatic function, and results in endotoxemia. Higher endotoxin levels in end-stage renal disease (ESRD) patients may result from the combination of decreased hepatic clearance function and increasing fraction of liver perfusion coming from toxin-laden portal vein during hemodialysis. The protective potential of dialysate cooling should be explored further in future research studies.
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Affiliation(s)
- Raanan Marants
- Department of Medical Biophysics, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada
| | - Elena Qirjazi
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada.,Division of Nephrology, Alberta Health Sciences, Calgary, Alberta, Canada
| | - Ka-Bik Lai
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Philip K T Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Fiona Li
- Department of Medical Biophysics, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Christopher W McIntyre
- Department of Medical Biophysics, Western University, London, Ontario, Canada.,The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
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Pietersen LC, Sarton E, Alwayn I, Lam HD, Putter H, van Hoek B, Braat AE. Impact of Temporary Portocaval Shunting and Initial Arterial Reperfusion in Orthotopic Liver Transplantation. Liver Transpl 2019; 25:1690-1699. [PMID: 31276282 DOI: 10.1002/lt.25592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 06/06/2019] [Indexed: 01/13/2023]
Abstract
The use of a temporary portocaval shunt (TPCS) as well as the order of reperfusion (initial arterial reperfusion [IAR] versus initial portal reperfusion) in orthotopic liver transplantation (OLT) is controversial and, therefore, still under debate. The aim of this study was to evaluate outcome for the 4 possible combinations (temporary portocaval shunt with initial arterial reperfusion [A+S+], temporary portocaval shunt with initial portal reperfusion, no temporary portocaval shunt with initial arterial reperfusion, and no temporary portocaval shunt with initial portal reperfusion) in a center-based cohort study, including liver transplantations (LTs) from both donation after brain death and donation after circulatory death (DCD) donors. The primary outcome was the perioperative transfusion of red blood cells (RBCs), and the secondary outcomes were operative time and patient and graft survival. Between January 2005 and May 2017, all first OLTs performed in our institution were included in the 4 groups mentioned. With IAR and TPCS, a significantly lower perioperative transfusion of RBCs was seen (P < 0.001) as well as a higher number of recipients without any transfusion of RBCs (P < 0.001). A multivariate analysis showed laboratory Model for End-Stage Liver Disease (MELD) score (P < 0.001) and IAR (P = 0.01) to be independent determinants of the transfusion of RBCs. When comparing all groups, no statistical difference was seen in operative time or in 1-year patient and graft survival rates despite more LTs with a liver from a DCD donor in the A+S+ group (P = 0.005). In conclusion, next to a lower laboratory MELD score, the use of IAR leads to a significantly lower need for perioperative blood transfusion. There was no significant interaction between IAR and TPCS. Furthermore, the use of a TPCS and/or IAR does not lead to increased operative time and is therefore a reasonable alternative surgical strategy.
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Affiliation(s)
- Lars Cornelis Pietersen
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Elise Sarton
- Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ian Alwayn
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hwai-Ding Lam
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Hein Putter
- Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart van Hoek
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Andries Erik Braat
- Division of Transplantation, Departments of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Order of liver graft revascularization in deceased liver transplantation: A systematic review and meta-analysis. Surgery 2019; 166:237-246. [PMID: 31085045 DOI: 10.1016/j.surg.2019.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/15/2019] [Accepted: 03/29/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The ideal order for liver graft revascularization during liver transplantation remains unknown. The majority of liver transplant centers prefer portal venous reperfusion followed by arterial reperfusion to shorten the warm ischemia time. The aim of this study was to review the different revascularization techniques used in clinical liver transplantation to identify any potential clinical benefits. METHODS A systematic search of 5 databases was performed to identify all available original articles that reported liver transplantation and compared different techniques of reperfusion. The primary outcomes were patient and graft survival. Secondary outcomes were defined by postreperfusion syndrome, primary nonfunction, vascular complications, biliary complications, and retransplantation. RESULTS A total of 1,160 patients undergoing liver transplantation from 15 studies were included in this review and meta-analysis. There were no differences regarding the 1-year patient and graft survival for the revascularization techniques. The incidence of primary nonfunction, vascular complications, and retransplantation did not differ between the groups. Although there were no differences regarding biliary complications between the different groups, there were more nonanastomotic strictures in patients with initial portal revascularization (9%) compared with those with simultaneous revascularization (2%; risk ratio 1.07; 95% confidence interval, 1.00-1.14; P = .05; I2 = 51%). CONCLUSION The order of liver graft revascularization does not influence patient and graft survival. Each revascularization technique offers potential benefits that can be used under specific clinical situations.
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Wang JZ, Liu Y, Wang JL, Lu L, Zhang YF, Lu HW, Li YM. Sequential vs simultaneous revascularization in patients undergoing liver transplantation: A meta-analysis. World J Gastroenterol 2015; 21:7036-46. [PMID: 26078582 PMCID: PMC4462746 DOI: 10.3748/wjg.v21.i22.7036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 01/08/2015] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM We undertook this meta-analysis to investigate the relationship between revascularization and outcomes after liver transplantation. METHODS A literature search was performed using MeSH and key words. The quality of the included studies was assessed using the Jadad Score and the Newcastle-Ottawa Scale. Heterogeneity was evaluated by the χ(2) and I (2) tests. The risk of publication bias was assessed using a funnel plot and Egger's test, and the risk of bias was assessed using a domain-based assessment tool. A sensitivity analysis was conducted by reanalyzing the data using different statistical approaches. RESULTS Six studies with a total of 467 patients were included. Ischemic-type biliary lesions were significantly reduced in the simultaneous revascularization group compared with the sequential revascularization group (OR = 4.97, 95%CI: 2.45-10.07; P < 0.00001), and intensive care unit (ICU) days were decreased (MD = 2.00, 95%CI: 0.55-3.45; P = 0.007) in the simultaneous revascularization group. Although warm ischemia time was prolonged in simultaneous revascularization group (MD = -25.84, 95%CI: -29.28-22.40; P < 0.00001), there were no significant differences in other outcomes between sequential and simultaneous revascularization groups. Assessment of the risk of bias showed that the methods of random sequence generation and blinding might have been a source of bias. The sensitivity analysis strengthened the reliability of the results of this meta-analysis. CONCLUSION The results of this study indicate that simultaneous revascularization in liver transplantation may reduce the incidence of ischemic-type biliary lesions and length of stay of patients in the ICU.
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Manzini G, Kremer M, Houben P, Gondan M, Bechstein WO, Becker T, Berlakovich GA, Friess H, Guba M, Hohenberger W, Ijzermans JNM, Jonas S, Kalff JC, Klar E, Klempnauer J, Lerut J, Lippert H, Lorf T, Nadalin S, Nashan B, Otto G, Paul A, Pirenne J, Pratschke J, Ringers J, Rogiers X, Schilling MK, Seehofer D, Senninger N, Settmacher U, Stippel DL, Tscheliessnigg K, Ysebaert D, Binder H, Schemmer P. Reperfusion of liver graft during transplantation: techniques used in transplant centres within Eurotransplant and meta-analysis of the literature. Transpl Int 2013; 26:508-16. [DOI: 10.1111/tri.12083] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 10/21/2012] [Accepted: 02/11/2013] [Indexed: 12/29/2022]
Affiliation(s)
- Giulia Manzini
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Michael Kremer
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Philipp Houben
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Matthias Gondan
- Institute of Medical Biometry and Informatics; University of Heidelberg; Heidelberg; Germany
| | - Wolf O. Bechstein
- Department of General and Visceral Surgery; Johann Wolfgang Goethe- University; Frankfurt am Main; Germany
| | - Thomas Becker
- Department of General and Thoracic Surgery; Christian-Albrechts-University Kiel; Kiel; Germany
| | | | - Helmut Friess
- Department of General Surgery; Klinikum Rechts der Isar; Technical University of Munich; Munich; Germany
| | - Markus Guba
- Department of General Surgery; Campus Grosshadern; University of Munich; Munich; Germany
| | - Werner Hohenberger
- Department of General Surgery; University of Erlangen; Erlangen; Germany
| | - Jan N. M. Ijzermans
- Department of Surgery; Erasmus Medisch Centrum-Daniel den Hoed; Rotterdam; Netherlands
| | - Sven Jonas
- Department of Visceral Transplant, Thoracic and Vascular Surgery; University of Leipzig; Leipzig; Germany
| | - Jörg C. Kalff
- Department of General Surgery; University of Bonn; Bonn; Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery; University of Rostock; Rostock; Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery; Klinikum der Medizinischen Hochschule; Hannover; Germany
| | - Jan Lerut
- Department of Liver Transplant Surgery; University Clinic Saint-Luc; Bruxelles; Belgium
| | - Hans Lippert
- Department of General, Visceral and Vascular Surgery; Otto-von-Guericke University; Magdeburg; Germany
| | - Thomas Lorf
- Department of General and Visceral Surgery; University of Goettingen; Goettingen; Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery; Eberhard-Karls University; Tuebingen; Germany
| | - Björn Nashan
- Department of Hepatobiliary and Transplant Surgery; University of Hamburg-Eppendorf; Hamburg; Germany
| | - Gerd Otto
- Department of Transplant and Hepato-biliary-pancreatic Surgery; Johannes-Gutenberg-University; Mainz; Germany
| | - Andreas Paul
- Department of General, Visceral and Transplant Surgery; University of Essen; Essen; Germany
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery; University of Leuven; Leuven; Belgium
| | - Johann Pratschke
- Department of Visceral, Transplant and Thoracic Surgery; University of Innsbruck; Innsbruck; Austria
| | - Jan Ringers
- Department of Transplant Surgery; University of Leiden; Leiden; Netherlands
| | - Xavier Rogiers
- Department of Transplant Surgery; University of Gent; Gent; Belgium
| | - Martin K. Schilling
- Department of General, Visceral, Vascular and Pediatric Surgery; University of Saarland; Homburg/Saar; Germany
| | - Daniel Seehofer
- Department of General, Visceral and Transplantation Surgery; Charité Campus Virchow-Klinikum; University of Berlin; Berlin; Germany
| | - Norbert Senninger
- Department of General and Visceral Surgery; University of Muenster; Muenster; Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery; Friedrich Schiller University; Jena; Germany
| | - Dirk L. Stippel
- Department of General, Visceral and Cancer Surgery; University of Cologne; Cologne; Germany
| | | | - Dirk Ysebaert
- Department of Hepatobiliary, Transplant and Endocrine Surgery; University Hospital of Antwerpen; Edegem; Belgium
| | - Heidrun Binder
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
| | - Peter Schemmer
- Department of General and Transplant Surgery; University of Heidelberg; Heidelberg; Germany
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Incidence of ischemic type biliary lesions after liver transplantation using piggyback technique and retrograde reperfusion. Eur Surg 2013. [DOI: 10.1007/s10353-012-0166-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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8
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Protection of the intrahepatic biliary tree by contemporaneous portal and arterial reperfusion: results of a prospective randomized pilot study. Updates Surg 2012; 64:173-7. [DOI: 10.1007/s13304-012-0164-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 06/21/2012] [Indexed: 01/26/2023]
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9
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Sequential versus contemporaneous portal and arterial reperfusion during liver transplantation. Transplant Proc 2011; 43:1107-9. [PMID: 21620064 DOI: 10.1016/j.transproceed.2011.01.123] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Although sequential portal and arterial revascularization (SPAr) is the most common method of graft reperfusion at liver transplantation (OLT), contemporaneous portal and hepatic artery revascularization (CPAr) has been used to reduce arterial ischemia to the bile ducts. The aim of this study was to prospectively compare SPAr (group 1; n=19) versus CPAr (group 2; n=21) among 40 consecutive OLT from heart-beating donors. There were no differences in the demographics characteristics, Model for End-stage Liver Disease scores, indication for OLT and donor parameters between the groups. OLT was performed using the piggyback technique. The biliary anastomosis was performed in all cases by a duct-to-duct technique with a T-tube in 32% versus 29% of cases without a T tube (P=.83). In the CPAr group, the liver was reperfused simultaneously via the portal vein and hepatic artery. CPAr showed a longer warm ischemia (66 ± 8 vs 37 ± 7 minutes; P<.001), while SPAr had a longer arterial ischemia 103 ± 42 vs 66 ± 8 minutes (P=.0004). Recovery of graft function was similar. There was no primary nonfunction and delayed graft function occurred among 10% versus 9%. Liver function tests were similar between the two groups up to 90 days case of follow-up- One-year graft and patient survivals were, respectively, 89% and 95% versus 94% and 100% (P=.29). At a median follow-up of 13 ± 6 versus 14 ± 7 months, biliary complications included anastomotic stenoses in 15% versus 19% (P=.78) and intrahepatic non-anastomotic biliary strictures in 26% versus none (P=.01) for SPAr and CPAr, respectively. CPAr was safe and feasible, reducing the incidence of intrahepatic biliary strictures by decreasing the duration of arterial ischemia to the intrahepatic bile ducts.
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Contemporaneous Portal-Arterial Reperfusion during Liver Transplantation: Preliminary Results. J Transplant 2011; 2011:251656. [PMID: 21559253 PMCID: PMC3087889 DOI: 10.1155/2011/251656] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 01/18/2011] [Accepted: 02/07/2011] [Indexed: 11/17/2022] Open
Abstract
We prospectively compared sequential portal-arterial revascularization (SPAr, group 1 no. 19) versus contemporaneous portal-hepatic artery revascularization (CPAr, group 2 no. 21) in 40 consecutive liver transplantation (LT). There were no differences in the demographics characteristics, MELD score, indication to LT, and donor's parameters between the two groups. CPAr had longer warm ischemia 66 ± 8 versus 37 ± 7 min (P < .001), while SPAr had longer arterial ischemia 103 ± 42 min (P = .0004). One-year patient's and graft survival were, respectively, 89% and 95% versus 94% and 100% (P = .29). At median followup of 13 ± 6 versus 14 ± 7 months biliary complications were anastomotic stenosis in 15% versus 19% (P = .78), and intrahepatic nonanastomotic biliary strictures in 26% versus none (P = .01), respectively, in SPAr and CPAr. CPAr reduces the incidence of intrahepatic biliary strictures by decreasing the duration of arterial ischemia.
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Polak WG, Peeters PM, Slooff MJ. The evolution of surgical techniques in clinical liver transplantation. A review. Clin Transplant 2009; 23:546-64. [DOI: 10.1111/j.1399-0012.2009.00994.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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12
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Ungerstedt J, Nowak G, Ungerstedt U, Ericzon BG. Microdialysis monitoring of porcine liver metabolism during warm ischemia with arterial and portal clamping. Liver Transpl 2009; 15:280-6. [PMID: 19242995 DOI: 10.1002/lt.21690] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Early detection of vascular complications following liver surgery is crucial. In the present study, intrahepatic microdialysis was used for continuous monitoring of porcine liver metabolism during occlusion of either the portal vein or the hepatic artery. Our aim was to assess whether microdialysis can be used to detect impaired vascular inflow by metabolic changes in the liver. Changes in metabolite concentrations in the hepatic interstitium were taken as markers for metabolic changes. After laparotomy, microdialysis catheters were introduced directly into the liver, enabling repeated measurements of local metabolism. Glucose, lactate, pyruvate, and glycerol were analyzed at bedside every 20 minutes, and the lactate/pyruvate ratio was calculated. In the arterial clamping group, the glucose, lactate, glycerol, and lactate/pyruvate ratio significantly increased during the 2-hour vessel occlusion and returned to baseline levels during the 3-hour reperfusion. In the portal occlusion group and in the control group, the measured metabolites were stable throughout the experiment. Our findings show that liver metabolism, as reflected by changes in the concentrations of glucose, lactate, and glycerol and in the lactate/pyruvate ratio, is markedly affected by occlusion of the hepatic artery. Surprisingly, portal occlusion resulted in no major metabolic changes. In conclusion, the microdialysis technique can detect and monitor arterial vascular complications of liver surgery, whereas potential metabolic changes in the liver induced by portal occlusion were not seen in the current study. Microdialysis may thus be suitable for use in liver surgery to monitor intrahepatic metabolic changes.
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Affiliation(s)
- Johan Ungerstedt
- Department of Physiology and Pharmacology, Karolinska University Hospital, Huddinge, Karolinska Institutet, Stockholm, Sweden.
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Bartlett A, Rela M, Heaton N. Reperfusion of the liver allograft with blue blood: is it still the royal perfusate? Am J Transplant 2007; 7:1689-91. [PMID: 17532754 DOI: 10.1111/j.1600-6143.2007.01834.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The technique of liver transplantation has become relatively standardized. Although not commonly practiced, arterial reperfusion has been shown in both animal and human trials to offer hemodynamic and functional benefits to liver allograft recipients. Whether this is the result of shortening the time to re-establishing arterial perfusion or an effect of the sequence which the liver is revascularized remains unknown. Further randomized clinical trials are needed to answer this question and support our practice of arterial reperfusion.
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Affiliation(s)
- A Bartlett
- Institute of Liver Studies, Kings College Hospital, Kings College School of Medicine and Dentistry at Denmark Hill, London, SE5 9RS, UK
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Moreno C, Sabaté A, Figueras J, Camprubí I, Dalmau A, Fabregat J, Koo M, Ramos E, Lladó L, Rafecas A. Hemodynamic profile and tissular oxygenation in orthotopic liver transplantation: Influence of hepatic artery or portal vein revascularization of the graft. Liver Transpl 2006; 12:1607-14. [PMID: 16724337 DOI: 10.1002/lt.20794] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We performed a prospective, randomized study of adult patients undergoing orthotopic liver transplantation, comparing hemodynamic and tissular oxygenation during reperfusion of the graft. In 30 patients, revascularization was started through the hepatic artery (i.e., initial arterial revascularization) and 10 minutes later the portal vein was unclamped; in 30 others, revascularization was started through the portal vein (i.e., initial portal revascularization) and 10 minutes later the hepatic artery was unclamped. The primary endpoints of the study were mean systemic arterial pressure and the gastric-end-tidal carbon dioxide partial pressure (PCO(2)) difference. The secondary endpoints were other hemodynamic and metabolic data. The pattern of the hemodynamic parameters and tissue oxygenation values during the dissection and anhepatic stages were similar in both groups At the first unclamping, initial portal revascularization produced higher values of mean pulmonary pressure (25 +/- 7 mm of Hg vs. 17 +/- 4 mm of Hg; P < 0.05) and wedge and central venous pressures. At the second unclamping, initial portal revascularization produced higher values of cardiac output and mean arterial pressure (87 +/- 15 mm of Hg vs. 79 +/- 15 mm of Hg; P < 0.05) and pulmonary blood pressure. Postreperfusion syndrome was present in 13 patients (42.5%) in the arterial group and in 11 patients (36%) in the portal group. During revascularization, the values of gastric and arterial pH decreased in both groups and recovered at the end of the procedure, but were more accentuated in the initial arterial revascularization group. In conclusion, we found that initial arterial revascularization of the graft increases pulmonary pressure less markedly, so it may be indicated for those patients with poor pulmonary and cardiac reserve. Nevertheless, for the remaining patients, initial portal revascularization offers more favorable hemodynamic and metabolic behavior, less inotropic drug use, and earlier normalization of lactate and pH values.
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Affiliation(s)
- Carlos Moreno
- Department of Anesthesiology, University Hospital of Bellvitge, Barcelona, Spain
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15
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Polak WG, Porte RJ. The sequence of revascularization in liver transplantation: it does make a difference. Liver Transpl 2006; 12:1566-70. [PMID: 17058245 DOI: 10.1002/lt.20797] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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16
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Saner FH, Nadalin S, Pavlaković G, Gu Y, Olde Damink SWM, Gensicke J, Fruhauf NR, Paul A, Radtke A, Sotiropoulos GC, Malagó M, Broelsch CE. Portopulmonary Hypertension in the Early Phase Following Liver Transplantation. Transplantation 2006; 82:887-91. [PMID: 17038902 DOI: 10.1097/01.tp.0000235520.37189.fe] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Portopulmonary hypertension (PPH) is a severe complication of liver cirrhosis, which poses a high risk for postliver transplantation (LT) mortality. In most liver transplant centers, severe PPH is viewed as an absolute contraindication for LT, but recent reports challenge this. The purpose of our study was to determine the incidence of PPH, its influence on the 30-day mortality rate following LT and to determine the sensitivity and specificity of Doppler echocardiography and electrocardiography as noninvasive tools to determine PPH. METHODS We studied 74 consecutive patients that underwent LT between February 2004 and November 2005. Pulmonary arterial pressure and cardiac index were repeatedly determined during surgery and postoperatively. PPH was defined as mild (mean pulmonary arterial pressure (MPAP) 25-35 mm Hg), moderate (MPAP of 35-45 mm Hg) and as severe (MPAP >45 mm Hg). RESULTS The total incidence of PPH was 31% (16 mild, 5 moderate, and 2 severe). There was a tendency towards increased 30-day mortality rate in patients with PPH compared to controls (22% vs. 12%, P=0.1). However, the two patients with the most severe PPH survived. The duration of ventilation and total stay at the intensive care unit did not differ significantly between groups. The positive predictive value of Doppler echocardiography for PPH was 39% and the negative predictive value 90%. CONCLUSIONS Mild pulmonary hypertension is common in patients with liver failure, whereas moderate and severe hypertension is not. Severe PPH should not be considered as absolute contraindication for LT.
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Affiliation(s)
- Fuat H Saner
- Department of General Surgery and Transplantation, University Clinic Essen, Germany
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Brockmann JG, August C, Wolters HH, Hömme R, Palmes D, Baba H, Spiegel HU, Dietl KH. Sequence of reperfusion influences ischemia/reperfusion injury and primary graft function following porcine liver transplantation. Liver Transpl 2005; 11:1214-22. [PMID: 16184569 DOI: 10.1002/lt.20480] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The impact of 3 different reperfusion sequences following orthotopic liver transplantation (OLT) in pigs were evaluated. The reperfusion technique commonly performed is primary portal in order to shorten warm ischemic times (WITs). Experimental and clinical data, usually comparing 2 out of 3 possible reperfusion sequences, provide controversial results. OLT was performed in 24 pigs randomized into 3 groups: primary arterial (A), simultaneous (SIM), and primary portal (P) reperfusion. Hemodynamics were continuously monitored and reperfusion injury and primary graft function were assessed by standard serum parameters, histopathological findings, immunohistochemistry for heme oxygenase 1 (HO-1), and heat shock protein 70 (HSP 70). Aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and gamma-glutamyl transpeptidase (gammaGT) following reperfusion were significantly increased for group A when compared to groups SIM and P. Hemodynamics showed significant differences after reperfusion compared to physiological data; differences in group comparisons were not significant. The bile production/100 g liver/hr was significantly higher for group SIM (1.15 mL) compared to group P (0.66 mL) and group A (0.62 mL). Histology and immunohistochemistry significantly correlated with functional results and outcome. Histological score was best for group SIM and worst for group A. HSP 70, being visualized mainly in the hepatocytes, showed higher expression for groups SIM and P. Inversely, HO-1, found in perisinusoidal cells, showed highest expression after primary arterial reperfusion. In conclusion, although associated with a 10-minute longer warm ischemic time, simultaneous reperfusion causes the least reperfusion injury with superior primary transplant function. Primary arterial reperfusion showed the worst overall outcome and highest degree of HO-1 expression.
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Affiliation(s)
- Jens G Brockmann
- Department of Surgical Research-General Surgery, University Hospital Münster, Germany
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Haberal M, Emiroglu R, Karakayali H, Moray G, Arslan G, Bilgin N, Demirhan B. Preliminary report on continous cold perfusion during vascular anastomosis in liver transplantation. Transplant Proc 2003; 35:2775-6. [PMID: 14612115 DOI: 10.1016/j.transproceed.2003.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M Haberal
- Baskent University Faculty of Medicine, Department of General Surgery and Transplantation, Ankara, Turkey.
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Kniepeiss D, Iberer F, Grasser B, Schaffellner S, Stadlbauer V, Tscheliessnigg KH. A single-center experience with retrograde-reperfusion in liver transplantation. Transpl Int 2003. [DOI: 10.1111/j.1432-2277.2003.tb00232.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Walsh TS, Garden OJ, Lee A. Metabolic, cardiovascular, and acid-base status after hepatic artery or portal vein reperfusion during orthotopic liver transplantation. Liver Transpl 2002; 8:537-44. [PMID: 12037785 DOI: 10.1053/jlts.2002.33481] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
During liver transplantation, reperfusion traditionally is performed through the portal vein. After anecdotal observations that patients who underwent reperfusion first through the hepatic artery were more hemodynamically stable, we performed an exploratory, prospective, observational, nonrandomized study to compare cardiovascular stability, acid-base status, and metabolic gas exchange between patients who underwent reperfusion through either the portal vein or hepatic artery. We studied 20 patients undergoing liver transplantation (10 patients, reperfusion first through the portal vein; 10 patients, reperfusion first through the hepatic artery). Cardiovascular and acid-base parameters were compared at times before and after anastomosis of each vessel, and epinephrine use was recorded. Oxygen consumption (VO2) and carbon dioxide elimination (VCO2) were measured continuously by using an indirect calorimeter. Alanine aminotransferase (ALT) concentrations 24 hours after transplantation were compared as an index of reperfusion injury. Cardiovascular changes (mean arterial pressure, cardiac output) were similar for both groups, but more epinephrine was administered to the portal-vein group (P =.014). There was a greater increase in PaCO2 after portal reperfusion (median portal vein, 1.01 kPa; hepatic artery, 0.29 kPa; P =.015) and a trend toward more severe acidemia. VO2 increased more rapidly in the portal-vein group (P =.005), but overall changes in VO2 during the study period were similar. There were no differences in VCO2 between the groups or ALT concentrations 24 hours posttransplantation. These observational data suggest that hepatic arterial reperfusion may be associated with reduced epinephrine requirements and a slower rate of acid release, which could be advantageous in unstable patients. VO2 increases more slowly after hepatic artery reperfusion, which could indicate slower reoxygenation of the graft. Further studies of the relative merits of each technique are warranted.
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Affiliation(s)
- Timothy S Walsh
- Department of Clinical and Surgical SciencesRoyal Infirmary of Edinburgh, Scotland.
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