Parietal Peritoneum as a Novel Substitute for Middle Hepatic Vein Reconstruction During Living Donor Liver Transplantation

Ex vivo resection, vessel reconstruction and liver autotransplantation for cholangiocarcinoma: A report of two cases

PURPOSE

Ex vivo liver resection and autotransplantation (ERAT) can be used to treat locally advanced tumors that are conventionally unresectable. Because the procedure is rare, there are very few reports in the literature. Recently, we performed ERAT for two cases of cholangiocarcinoma invading caudate lobe, the retrohepatic vena cava and hepatic veins, and investigated technical variations of this procedure.

METHODS

One patient was a 57-year-old man with liver caudate lobe metastasis from cholangiocarcinoma after pancreaticoduodenal resection five years ago, and the other patient was a 68-year-old man with caudate lobe cholangiocarcinoma. Both cases were considered to be unresectable by conventional resection due to the critical invasion of the retrohepatic vena cava along with the three hepatic veins. Therefore, ERAT was indicated in these two cases.

RESULTS

The liver along with the retrohepatic vena cava was removed, which was replaced by GORE-TEX synthetic artificial vessel grafts with angioplasty to reconstruct the inferior vena cava (IVC), and the GORE-TEX synthetic artificial vessel anastomosed to the right auricular appendage or the IVC to build the continuity of the IVC. Ex vivo caudate lobe hepatectomy was performed, along with the retrohepatic vena cava and hepatic veins, and subsequently the reconstruction outflow of hepatic venous was established using cold-preserved allogeneic vessels and falciform ligament. Finally, remnant of the liver was implanted by Piggyback liver transplantation. The hepatic vein, portal vein, hepatic artery and bile duct were anastomosed, and autotransplantation of the liver was completed. The patients were followed-up for 18 months and showed good liver function, with no recurrence of cancer.

CONCLUSIONS

ERAT should be considered as a therapeutic option for selected patients with cholangiocarcinoma invading caudate lobe, the retrohepatic vena cava and hepatic veins. It is crucial to reconstruct the outflow of hepatic venous according to different situations.

Technical challenges in LDLT - Overcoming small for size syndrome and venous outflow reconstruction

Living Donor Liver Transplantation (LDLT) emerged as an alternative treatment option for patients with end-stage liver disease waiting for an organ from a deceased donor. In addition to allowing for a faster access to transplantation, LDLT provides improved recipient outcomes when compared to deceased donor LT. However, it represents a more complex and demanding procedure for the transplant surgeon. In addition to a comprehensive preoperative donor assessment and stringent technical considerations during the donor hepatectomy to ensure upmost donor safety, the recipient procedure also comes with intrinsic challenges during LDLT. A proper approach during both procedures will result in favorable donor and recipient's outcomes. Hence, it is critical for the transplant surgeon to know how to overcome such technical challenges and avoid deleterious complications. One of the most feared complications following LDLT is small-for-size syndrome (SFSS). Although, surgical advances and deeper understanding of the pathophysiology behind SFSS has allowed for a safer implementation of LDLT, there is currently no consensus on the best strategy to prevent or manage this complication. Therefore, we aim to review current practices in technically challenging situations during LDLT, with a particular focus on management of small grafts and venous outflow reconstructions, as they possess one of the biggest technical challenges faced during LDLT.

Pure Laparoscopic vs. Open Right Hepatectomy in Living Liver Donors: Bench-Surgery Time

Background: Recently, there have been several reports on pure laparoscopic donor right hepatectomy (PLDRH), but the effect of pure laparoscopy on bench surgery has not been evaluated. This study aimed to compare bench-surgery time between PLDRH and conventional donor right hepatectomy (CDRH).

Methods: We retrospectively reviewed the medical records of 758 live liver donors between January 2012 and December 2019. We divided the patients into two groups: between January 2012 and September 2015, when we exclusively performed CDRH, and between March 2016 and December 2019, when PLDRH was standardized. We excluded all other types of graft donor hepatectomy, laparoscopic assisted donor hepatectomy, and cases with no recorded data.

Results: In total, 267 donors were included in the PLDRH group and were compared with 247 donors in the CDRH group. Similar proportions of graft vascular variations were observed between the two groups. The mean bench-surgery time was longer in the PLDRH group than in the CDRH group (49.3 ± 19.9 vs. 39.5 ± 17.5 min; P < 0.001).

Conclusion: The bench-surgery time was longer in the PLDRH group than the CDRH group, regardless of whether the vascular network was reconstructed. Expertise in bench-surgery as well as donor surgery and recipient surgery is mandatory for PLDRH to be safe and feasible.