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Elkomos B, Alkomos P, Junaid Saleem R, Ebeidallah G, Hanna J, Abdelaal A. A Systematic Review and Meta-Analysis: Do We Still Need Microscope Surgery in Hepatic Artery Anastomosis to Decrease the Incidence of Complications in Living Donor Liver Transplantation? Cureus 2023; 15:e48112. [PMID: 37920422 PMCID: PMC10619707 DOI: 10.7759/cureus.48112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 11/04/2023] Open
Abstract
Hepatic artery thrombosis (HAT) is the most serious vascular complication after liver transplantation (LT). Moreover, in comparison to deceased donor liver transplantation (DDLT), hepatic artery (HA) anastomosis is more challenging in living donor liver transplantation (LDLT) with a lot of controversial topics about the use of microscopic surgery. We aimed to compare the use of microscopic and loupe surgery in HA anastomosis in adult and pediatric LDLT to decrease the incidence of vascular complications. We searched PubMed, Scopes, Web of Science, and Cochrane Library for eligible studies from inception to April 2023 and a systematic review and a meta-analysis were done. According to our eligibility criteria, 10 studies with a total of 1939 patients were included. In comparison to microscopic surgery, loupe anastomosis has a similar incidence of HAT (thrombosis, risk ratio (RR) = 0.96, 95% CI = 0.26-3.48, P = 0.95). In addition to that, no significant difference was detected between the two types in terms of stenosis, decreased blood flow and hospital stay (decreased blood flow, RR = 0.68, 95% CI = 0.01-86.65, P = 0.88), (stenosis, RR = 1.81, 95% CI = 0.19-17.21, P = 0.60), (hospital stay, mean deviation (MD) = 1.16, 95% CI = -3.79-6.11, P = 0.65). However, the anastomotic time was longer in the case of microscopic surgery (anastomotic time, MD = 24.09, 95% CI = 7.79-40.39, P = 0.004). With an equal incidence of complications and longer anastomotic time, there is no added benefit of the routine use of microscopic surgery in HA anastomosis in LDLT.
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Affiliation(s)
| | | | | | - Guirgis Ebeidallah
- Acute and Emergency Medicine, Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, GBR
| | - Joseph Hanna
- General Surgery, Manchester Foundation Trust, Manchester, GBR
| | - Amr Abdelaal
- General Surgery, Ain Shams University, Cairo, EGY
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Technique of Hepatic Artery Anastomosis in Living Donor Liver Transplantation: Review of Its Results in Over 1200 Adult and Pediatric Transplants. World J Surg 2023; 47:759-763. [PMID: 36459197 DOI: 10.1007/s00268-022-06853-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Failure to achieve a good arterial inflow to the graft in living donor liver transplantation (LDLT) has disastrous consequences to the graft and patient survival. Standard microvascular techniques of hepatic artery (HA) anastomosis used in deceased donor liver transplantation are not applicable in LDLT. We present the results of our unique Backwall-first technique of HA anastomosis in both adult and pediatric LDLT. PATIENTS AND METHODS Retrospective review of all consecutive patients who underwent LDLT from January 2010 to December 2020 was performed from our prospective database. Data with regard to early postoperative (90-day) hepatic arterial complications were analyzed. RESULTS A total of 1276 LDLTs (876 adults, 400 children) were performed during the study period. In the 90-day postoperative period, HA anastomotic complications [thrombosis in 11 (0.9%); pseudoaneurysm in 3 (0.2%)] were observed in 14 recipients (1.1%) including 8 adults (0.9%) and 6 children (1.5%). Eight of these 14 recipients (0.6%) including 4 adults (0.5%) and 4 children (1%) had standard HA reconstruction. The remaining six (0.5%) including 4 adults and 2 children had complex arterial reconstruction with interposition graft and/or alternative arterial inflow. CONCLUSION The Backwall-first technique of HA reconstruction described in this study achieved a very low HA complication rate in LDLT.
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Yilmaz S, Kutluturk K, Usta S, Akbulut S. Techniques of hepatic arterial reconstruction in liver transplantation. Langenbecks Arch Surg 2022; 407:2607-2618. [PMID: 36018429 DOI: 10.1007/s00423-022-02659-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/18/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hepatic artery reconstruction is an essential part of liver transplantation. This difficult stage of the operation is even more demanding in living donor liver transplantation than in deceased donor liver transplantation. One of the most important advances in hepatic artery reconstruction for living liver grafts was the introduction of microsurgical techniques involving an operative microscope or surgical loupe. Many surgical reconstruction techniques have been used in this field. PURPOSE In this article, first, we will talk about the hepatic artery reconstruction techniques that are frequently used in deceased donor liver transplantation, and afterward, we will talk about the hepatic artery reconstruction techniques used in living donor liver transplantation, which include the hepatic artery reconstruction technique we use and call "one stay corner suture technique". CONCLUSIONS We think high-volume transplant centers should tend to develop a standardized technique for doing hepatic artery reconstruction with their teams. We think the "one stay corner suture technique" can be easily applied in centers that perform LDLT.
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Affiliation(s)
- Sezai Yilmaz
- Department of Surgery and Liver Transplant Institute, Faculty of Medicine, Inonu University, Elazig Yolu 10. Km, 44280, Malatya, Turkey
| | - Koray Kutluturk
- Department of Surgery and Liver Transplant Institute, Faculty of Medicine, Inonu University, Elazig Yolu 10. Km, 44280, Malatya, Turkey
| | - Sertac Usta
- Department of Surgery and Liver Transplant Institute, Faculty of Medicine, Inonu University, Elazig Yolu 10. Km, 44280, Malatya, Turkey
| | - Sami Akbulut
- Department of Surgery and Liver Transplant Institute, Faculty of Medicine, Inonu University, Elazig Yolu 10. Km, 44280, Malatya, Turkey.
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Nickel KJ, Morzycki A, Visser L, Bell E, Ladak A. Effect of magnification in pediatric liver transplantation: A systematic review and meta-analysis. Pediatr Transplant 2022; 26:e14223. [PMID: 35001466 DOI: 10.1111/petr.14223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 11/28/2021] [Accepted: 12/29/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hepatic artery thrombosis (HAT) represents a devastating and often fatal complication of liver transplantation. Due to the small vessel caliber in pediatric patients, the use of an operating microscope has largely become the standard for hepatic artery reconstruction to reduce the rate of HAT. Recent evidence, however, suggests that loupe magnification for anastomosis may be equally effective. We aimed to determine the effect of magnification on the rate of hepatic artery thrombosis in pediatric liver transplantation. METHODS A systematic search of the literature was conducted. Thousand eighty-eight unique titles were assessed by two independent reviewers. Studies directly comparing rates of HAT from loupe magnification and operating microscope-assisted anastomoses were eligible for meta-analysis. RESULTS Among primary transplants, the rate of HAT was 6.0%. Operating microscope anastomosis was associated with a 2.6% decrease in the rate of HAT compared to that of loupe magnification (4.9% and 7.4%, respectively, p < .040). When re-transplants were included, the rate of HAT was 5.8%. Operating microscope anastomosis was associated with a 1.0% decrease in the rate of HAT compared to that of loupe magnification (5.3% and 6.3%, respectively, p < .279). Meta-analysis of eligible studies demonstrated a reduction in the rate of HAT with the use of an operating microscope (p < .03). CONCLUSIONS Anastomosis under an operating microscope may be associated with decreased rates of HAT in children undergoing primary liver transplantation. Further high-quality studies comparing the two techniques are needed.
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Affiliation(s)
- Kevin J Nickel
- Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Alexander Morzycki
- Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Lloyd Visser
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Adil Ladak
- Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, Alberta, Canada
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Ebner PJ, Bick KJ, Emamaullee J, Stanton EW, Gould DJ, Patel KM, Genyk Y, Sher L, Carey JN. Microscope-Assisted Arterial Anastomosis in Adult Living Donor Liver Transplantation: A Systematic Review and Meta-analysis of Outcomes. J Reconstr Microsurg 2021; 38:306-312. [PMID: 34428807 DOI: 10.1055/s-0041-1732349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) has expanded the availability of liver transplant but has been associated with early technical complications including the devastating complication of hepatic artery thrombosis (HAT), which has been reported to occur in 14% to 25% of LDLT using standard anastomotic techniques. Microvascular hepatic artery reconstruction (MHAR) has been implemented in an attempt to decrease rates of HAT. The purpose of this study was to review the available literature in LDLT, specifically related to MHAR to determine its impact on rates of posttransplant complications including HAT. METHODS A systematic review was conducted using PubMed/Medline and Web of Science. Case series and reviews describing reports of microscope-assisted hepatic artery anastomosis in adult patients were considered for meta-analysis of factors contributing to HAT. RESULTS In all, 462 abstracts were screened, resulting in 20 studies that were included in the meta-analysis. This analysis included 2,457 patients from eight countries. The pooled rate of HAT was 2.20% with an overall effect size of 0.00906. CONCLUSION Systematic literature review suggests that MHAR during LDLT reduces vascular complications and improves outcomes posttransplant. Microvascular surgeons and transplant surgeons should collaborate when technical challenges such as small vessel size, short donor pedicle, or dissection of the recipient vessel wall are present.
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Affiliation(s)
- Peggy J Ebner
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Katherine J Bick
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Juliet Emamaullee
- Keck School of Medicine, University of Southern California, Los Angeles, California.,Division of Hepatobiliary and Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Eloise W Stanton
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Daniel J Gould
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Yuri Genyk
- Keck School of Medicine, University of Southern California, Los Angeles, California.,Division of Hepatobiliary and Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Linda Sher
- Keck School of Medicine, University of Southern California, Los Angeles, California.,Division of Hepatobiliary and Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Southern California, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
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Nickel KJ, Staples J, Meeberg G, Kwan PO, Gilmour S, Bigam DL, Dajani K, Shapiro AMJ, Kneteman NM, Ladak A. The Transition to Microsurgical Technique for Hepatic Artery Reconstruction in Pediatric Liver Transplantation. Plast Reconstr Surg 2021; 148:248e-257e. [PMID: 34181598 DOI: 10.1097/prs.0000000000008169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Hepatic artery thrombosis represents a potentially fatal complication following liver transplantation. Rates of hepatic artery thrombosis are significantly higher in children, with mortality reported up to 80 percent. Microsurgical anastomosis has been shown to decrease the rate of hepatic artery thrombosis and now represents the standard of care at the authors' institution. In this article, the authors present the largest study of its type directly comparing rates of hepatic artery thrombosis with and without microsurgical reconstruction of the hepatic artery. METHODS All pediatric patients who underwent primary orthotopic liver transplantation between 1989 and 2018 were included. Patients were divided into two cohorts: standard anastomosis with loupes, and microsurgical anastomosis under the operating microscope. The authors' primary outcome was the rate of hepatic artery thrombosis. Secondary outcomes were graft survival, patient survival, retransplantation rate, requirement for intraoperative blood products, and length of stay. RESULTS Two hundred thirty-one children met criteria for inclusion. One hundred eighty cases were performed with loupe magnification and 51 cases were performed under the microscope. The hepatic artery thrombosis rate was lower, but not significantly so (p = 0.114), in the microsurgical group [n = 1 (2.0 percent)] compared with the standard cohort [n = 15 (8.3 percent)]. Survival analysis revealed a significant increase in graft survival with microsurgical anastomosis (p = 0.020), but not patient survival (p = 0.196). The retransplantation rate was significantly lower with microsurgical anastomosis (p = 0.021). CONCLUSIONS Microsurgical anastomosis was associated with a clinically important decrease in hepatic artery thrombosis compared with standard loupe anastomosis. The graft survival rate was significantly higher in the microsurgical cohort, with a reduced retransplantation rate at 1 year. On this basis, the authors recommend microsurgical hepatic artery anastomosis in cases of pediatric liver transplantation. . CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Kevin J Nickel
- From the Divisions of Plastic Surgery, General and Transplant Surgery, and Pediatric Gastroenterology, University of Alberta
| | - John Staples
- From the Divisions of Plastic Surgery, General and Transplant Surgery, and Pediatric Gastroenterology, University of Alberta
| | - Glenda Meeberg
- From the Divisions of Plastic Surgery, General and Transplant Surgery, and Pediatric Gastroenterology, University of Alberta
| | - Peter O Kwan
- From the Divisions of Plastic Surgery, General and Transplant Surgery, and Pediatric Gastroenterology, University of Alberta
| | - Susan Gilmour
- From the Divisions of Plastic Surgery, General and Transplant Surgery, and Pediatric Gastroenterology, University of Alberta
| | - David L Bigam
- From the Divisions of Plastic Surgery, General and Transplant Surgery, and Pediatric Gastroenterology, University of Alberta
| | - Khaled Dajani
- From the Divisions of Plastic Surgery, General and Transplant Surgery, and Pediatric Gastroenterology, University of Alberta
| | - A M James Shapiro
- From the Divisions of Plastic Surgery, General and Transplant Surgery, and Pediatric Gastroenterology, University of Alberta
| | - Norman M Kneteman
- From the Divisions of Plastic Surgery, General and Transplant Surgery, and Pediatric Gastroenterology, University of Alberta
| | - Adil Ladak
- From the Divisions of Plastic Surgery, General and Transplant Surgery, and Pediatric Gastroenterology, University of Alberta
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Akbulut S, Kutluturk K, Yilmaz S. Hepatic artery reconstruction technique in liver transplantation: experience with 3,000 cases. Hepatobiliary Surg Nutr 2021; 10:281-283. [PMID: 33898579 DOI: 10.21037/hbsn-21-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Sami Akbulut
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Koray Kutluturk
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Sezai Yilmaz
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya, Turkey
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Impact of Microsurgical Anastomosis of Hepatic Artery on Arterial Complications and Survival Outcomes After Liver Transplantation. Transplant Proc 2020; 53:65-72. [PMID: 32951861 DOI: 10.1016/j.transproceed.2020.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/20/2020] [Accepted: 08/08/2020] [Indexed: 12/28/2022]
Abstract
Hepatic artery (HA) complications after liver transplant (LT) can lead to biliary complications, graft failure, and mortality. Although microsurgery has been established to improve anastomotic outcomes, it prolongs surgical time and has not reached widespread adoption at all transplant centers. We investigated the incidences of arterial, biliary complications and outcomes after using microsurgery to anastomose HA during LT. Retrospective cohort of consecutive LT performed from 2006 to 2018 was reviewed for operative details and postoperative outcomes. Cox-regression models were used to investigate the relationship between variables and outcomes. Eighty (62.5%) LTs (Group 1) were performed without and compared with 48 (Group 2) with microsurgical anastomosis of HA. Both groups were comparable in terms of arterial and biliary anastomoses performed. Incidence of early HA thrombosis was similar (6.2% vs 2.1%, P = .28). Group 2 had lower incidence of short- and long-term arterial complications, especially amongst living donor liver transplantations (LDLT) (5.3% vs 35.0%, P = .022). On multivariate analysis, microsurgery was associated with lower risk (hazard ratio [HR] 0.09, 95% confidence interval [CI] 0.01-0.71) of, and LDLT had higher risk (HR 4.23, 95% CI 1.46-12.27) of arterial complications. Biliary complications were associated with LDLT (HR 3.91, 95% CI 1.30-11.71) and dual biliary anastomoses (HR 5.26, 95% CI 1.15-24.08) but not with occurrence of HA complications. Worse patient survival was associated with the occurrence of any HA complication (HR 4.11, 95% CI 1.78-9.48). Hepatic arterial complications can be reduced using microsurgical techniques for the anastomosis, resulting in improved patient survival outcomes after liver transplantation.
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9
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Balci D, Ahn CS. Hepatic artery reconstruction in living donor liver transplantation. Curr Opin Organ Transplant 2019; 24:631-636. [DOI: 10.1097/mot.0000000000000697] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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10
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Microvascular Hepatic Artery Anastomosis in Pediatric Living Donor Liver Transplantation: 73 Consecutive Cases Performed by a Single Surgeon. Plast Reconstr Surg 2019; 142:1609-1619. [PMID: 30239502 DOI: 10.1097/prs.0000000000005044] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Living donor liver transplantation is an important strategy of procuring segmental liver allografts for pediatric patients with liver failure, as suitably sized whole donor organs are scarce. The early pediatric living donor liver transplantation experience was associated with high rates of hepatic artery thrombosis, graft loss, and mortality. Collaboration with microsurgeons for hepatic artery anastomosis in pediatric living donor liver transplantation has decreased rates of arterial complications; however, reported outcomes are limited. METHODS A 14-year retrospective review was undertaken of children at the authors' institution who underwent living donor liver transplantation with hepatic artery anastomosis performed by a single microsurgeon using an operating microscope. Data were collected on demographics, cause of liver failure, graft donor, vessel caliber, vessel anastomosis, arterial complications, and long-term follow-up. RESULTS Seventy-three children with end-stage liver failure underwent living donor liver transplantation with microvascular hepatic artery anastomosis. The commonest cause for liver failure was biliary atresia (63 percent). A total of 83 end-to-end hepatic artery anastomoses were completed using an operating microscope. Hepatic artery complications occurred in five patients, consisting of three cases of kinked anastomoses that were revised without complications and two cases of hepatic artery thrombosis (3 percent), of which one resulted in graft loss and patient death. Patient survival was 94 percent at 1 year and 90 percent at 5 years. CONCLUSIONS Microvascular hepatic artery anastomosis in pediatric patients undergoing living donor liver transplantation is associated with a low hepatic artery complication rate and excellent long-term liver graft function. Collaboration between microsurgeons and transplant surgeons can significantly reduce technical complications and improve patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Abstract
Living donor liver transplantation (LDLT) has been increasingly embraced around the world as an important strategy to address the shortage of deceased donor livers. The aim of this guideline, approved by the International Liver Transplantation Society (ILTS), is to provide a collection of expert opinions, consensus, and best practices surrounding LDLT. Recommendations were developed from an analysis of the National Library of Medicine living donor transplantation indexed literature using the Grading of Recommendations Assessment, Development and Evaluation methodology. Writing was guided by the ILTS Policy on the Development and Use of Practice Guidelines (www.ilts.org). Intended for use by physicians, these recommendations support specific approaches to the diagnostic, therapeutic, and preventive aspects of care of living donor liver transplant recipients. Compared to cadaveric liver transplantation, live donor LT (LDLT) is challenged by ethical, medical and surgical considerations, many of which are still unresolved. The aim of this guideline is to provide a collection of expert opinions, consensus, and best practices surrounding LDLT.
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12
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Koh PS, Chan SC. Adult-to-adult living donor liver transplantation: Operative techniques to optimize the recipient's outcome. J Nat Sci Biol Med 2017; 8:4-10. [PMID: 28250667 PMCID: PMC5320821 DOI: 10.4103/0976-9668.198356] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Adult-to-adult living donor liver transplantation (LDLT) is widely accepted today with good outcomes and safety reported worldwide for both donor and recipient. Nonetheless, it remained a highly demanding technical and complex surgery if undertaken. The last two decades have seen an increased in adult-to-adult LDLT following our first report of right lobe LDLT in overcoming graft size limitation in adults. In this article, we discussed the operative techniques and challenges of adult right lobe LDLT incorporating the middle hepatic vein, which is practiced in our center for the recipient operation. The various issues and challenges faced by the transplant surgeon in ensuring good recipient outcome are explored and discussed here as well. Hence, it is important to understand that a successful recipient operation is dependent of multifactorial events starting at the preoperative stage of planning, understanding the intraoperative technical challenges and the physiology of flow modulation that goes hand-in-hand with the operation. Therefore, one needs to arm oneself with all the possible knowledge in overcoming these technical challenges and the ability to be flexible and adaptable during LDLT by tailoring the needs of each patient individually.
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Affiliation(s)
- Peng Soon Koh
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - See Ching Chan
- Department of Surgery, The University of Hong Kong, Hong Kong, SAR, China
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Takagi K, Yagi T, Yoshida R, Shinoura S, Umeda Y, Nobuoka D, Watanabe N, Kuise T, Sui K, Hirose A, Tsuboi M, Ogasawara M, Iwasaki S, Saibara T, Fujiwara T. A successful case of deceased donor liver transplantation for a patient with intrahepatic arterioportal fistula. Hepatol Res 2016; 46:1409-1415. [PMID: 26990240 DOI: 10.1111/hepr.12701] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 02/17/2016] [Accepted: 03/01/2016] [Indexed: 12/31/2022]
Abstract
Intrahepatic arterioportal fistula (IAPF) is a rare cause of portal hypertension that is often difficult to treat with interventional radiology or surgery. Liver transplantation for IAPF is extremely rare. We report a case of bilateral diffuse IAPF with severe portal hypertension requiring deceased donor liver transplantation (DDLT). A 51-year-old woman with no past medical history was admitted to another hospital complaining of abdominal distension and marasmus. A computed tomography scan and digital subtraction angiography indicated a massive pleural effusion, ascites, and a very large IAPF. Several attempts of interventional embolization of the feeding artery failed to ameliorate arterioportal shunt flow. As ruptures of the esophageal varices became more frequent, hepatic encephalopathy worsened. After repeated, uncontrollable attacks of hepatic coma, the patient was referred to our facility for further treatment. Surgical approaches to IAPF other than liver transplantation were challenging because of diffuse collateralization; therefore, we placed the patient on the national waiting list for DDLT. Although her Model for End-Stage Liver Disease score was relatively low, she received a DDLT 2 months after the waiting period. The postoperative course was uneventful, and the patient was discharged 44 days after her transplant. Liver transplantation may be a valid treatment option for uncontrollable IAPF with severe portal hypertension.
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Affiliation(s)
- Kosei Takagi
- Hepato-Biliary and Pancreatic Surgery, Okayama University Hospital, Okayama, Japan
| | - Takahito Yagi
- Hepato-Biliary and Pancreatic Surgery, Okayama University Hospital, Okayama, Japan
| | - Ryuichi Yoshida
- Hepato-Biliary and Pancreatic Surgery, Okayama University Hospital, Okayama, Japan
| | - Susumu Shinoura
- Hepato-Biliary and Pancreatic Surgery, Okayama University Hospital, Okayama, Japan
| | - Yuzo Umeda
- Hepato-Biliary and Pancreatic Surgery, Okayama University Hospital, Okayama, Japan
| | - Daisuke Nobuoka
- Hepato-Biliary and Pancreatic Surgery, Okayama University Hospital, Okayama, Japan
| | - Nobuyuki Watanabe
- Hepato-Biliary and Pancreatic Surgery, Okayama University Hospital, Okayama, Japan
| | - Takashi Kuise
- Hepato-Biliary and Pancreatic Surgery, Okayama University Hospital, Okayama, Japan
| | - Kenta Sui
- Hepato-Biliary and Pancreatic Surgery, Okayama University Hospital, Okayama, Japan
| | - Akira Hirose
- Department of Gastroenterology and Hepatology, Kochi Medical School, Kochi, Japan
| | - Makiko Tsuboi
- Department of Gastroenterology and Hepatology, Kochi Medical School, Kochi, Japan
| | - Mitsunari Ogasawara
- Department of Gastroenterology and Hepatology, Kochi Medical School, Kochi, Japan
| | - Shinji Iwasaki
- Department of Gastroenterology and Hepatology, Kochi Medical School, Kochi, Japan
| | - Toshiji Saibara
- Department of Gastroenterology and Hepatology, Kochi Medical School, Kochi, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Transplant Surgery and Surgical Oncology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Tannuri ACA, Monteiro RF, Santos MM, Miyatani HT, Tannuri U. A new simplified technique of arterial reconstruction in pediatric living-donor liver transplantation: a comparison with the classical technique. J Pediatr Surg 2014; 49:1518-21. [PMID: 25280659 DOI: 10.1016/j.jpedsurg.2014.02.084] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 02/16/2014] [Accepted: 02/17/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND/AIM Hepatic artery anastomosis (HAA) is the most important aspect of living donor liver transplantation (LDLT), and it is currently performed by a specialized microsurgeon using micro surgical techniques, with interrupted sutures and the aid of an operative microscope. To simplify the procedure, we studied a new, simpler technique performed by pediatric transplant surgeons with continuous sutures and the same 3.5× magnification loupe used during other transplant procedures. The aim of this study was to compare these two hepatic artery reconstruction techniques in two pediatric LDLT series. METHODS This study was initiated in January 2010 and finished in June 2013. In the first period, the arterial reconstruction was performed with an operating microscope and the classical technique of 9-0 separate sutures. In the second period, the arterial reconstruction was performed using a simpler technique, with surgical loupe and continuous 8-0 Prolene sutures. The incidences and outcomes of complications within the two periods were analyzed and compared. RESULTS A total of 82 LDLTs were performed, 38 in the first period and 44 in the second period. There were no differences between the periods, except for the arterial ischemia time, which was lower in the second period. CONCLUSION Hepatic artery anastomosis can be safely performed with low complication rates by a pediatric transplant surgeon using continuous sutures with a 3.5× magnifying loupe. This technique is simpler, less time consuming and simplifies the complex pediatric LDLT procedure.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao, Paulo Medical School, Sao Paulo, Brazil
| | - Roberta Figueiredo Monteiro
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao, Paulo Medical School, Sao Paulo, Brazil
| | - Maria Mercês Santos
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao, Paulo Medical School, Sao Paulo, Brazil
| | - Helena Thie Miyatani
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao, Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao, Paulo Medical School, Sao Paulo, Brazil.
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