The utility of recanalized umbilical vein graft to the hepato-pancreato-biliary surgeon

Portal vein wedge resection and patch venoplasty with autologous vein grafts for hepatobiliary-pancreatic cancer

BACKGROUND

Advanced hepatobiliary-pancreatic cancer often invades critical blood vessels, including the portal vein (PV) and hepatic artery. Resection with tumor-free resection margins is crucial to achieving a favorable prognosis in these patients. Herein, we present our cases and surgical techniques for PV wedge resection with patch venoplasty using autologous vein grafts during surgery for pancreatic ductal adenocarcinoma (PDAC) and perihilar cholangiocarcinoma (PhCC).

CASE PRESENTATION

Case 1: 73-year-old female patient with PDAC; underwent subtotal stomach-preserving pancreatoduodenectomy, with superior mesenteric vein wedge resection and venoplasty with the right gonadal vein. Case 2: 67-year-old male patient with PDAC; underwent distal pancreatectomy and celiac axis resection, with PV wedge resection and venoplasty with the middle colic vein. Case 3: 51-year-old female patient with type IV PhCC; underwent left hepatectomy with caudate lobectomy and bile duct resection, with hilar PV wedge resection and venoplasty with the inferior mesenteric vein (IMV). Case 4: 69-year-old male patient with type IIIA PhCC; underwent right hepatopancreatoduodenectomy, with hilar PV resection and patch venoplasty with the IMV. All patients survived for over 12 months after the surgery, without local recurrence.

CONCLUSIONS

PV wedge resection and patch venoplasty is a useful technique for obtaining tumor-free margins in surgeries for hepatobiliary-pancreatic cancer.

The rex shunt for left portal vein reconstruction during hepatectomy for malignancy using of rex-shunt in adults for oncoliver surgery

BACKGROUND

Immediate portal reperfusion is mandatory following hepatectomy combined with portal vein (PV) resection. This retrospective study analyzes the feasibility and the outcomes of the Rex shunt (RS) for reconstruction of the left portal vein (LPV) and reperfusion of the remnant left liver or lobe following hepatectomy for cancer combined with resection of the PV in adult patients.

METHODS

From 2018 to 2021, an RS was used in the above setting to achieve R0 resection or when the standard LPV reconstruction failed or was deemed technically impossible.

RESULTS

There were 6 male and 5 female patients (median age, 58 years) with perihilar cancer (5 cases) or miscellaneous cancers invading the PV (6 cases). A major hepatectomy was performed in 10/11 patients. The RS was indicated to achieve R0 resection or for technical reasons in 8 and 3 cases, respectively, and was feasible in all consecutive attempts with (10 cases) or without an interposed synthetic graft (1 case). Two fatal complications (PV thrombosis and pulmonary embolism) and three non-severe complications occurred in four patients within 90 days of surgery. Two patients died of tumor recurrence with a patent RS at 13 and 29 months, and 7 were recurrence free with a patent shunt with a follow-up of 1 to 37 months (median, 15 months).

CONCLUSION

In case of remnant left liver or lobe following hepatectomy combined with resection of the PV, the RS may help to achieve R0 resection and is a valuable option to perform technically satisfying portal reperfusion of the remnant left liver or lobe.

Meso-Rex bypass for the management of extrahepatic portal vein obstruction in adults (with video)

BACKGROUND

Extrahepatic portal vein obstruction (EHPVO) results in severe portal hypertension (PHT) leading to severely compromised quality of life. Often, pharmacological and endoscopic management is unable to solve this problem. Restoring hepatic portal flow using meso-Rex bypass (MRB) may solve it. This procedure, uncommon in adult patients, is considered the treatment of choice for EHPVO in children.

METHODS

From 1997 to 2018, 8 male and 6 female adults, with a median age of 51 years (range 22-66) underwent MRB procedure for EHPVO at the University Hospitals Saint-Luc in Brussels, Belgium. Symptoms of PHT were life altering in all but one patient and consisted of repetitive gastro-intestinal bleedings, sepsis due to portal biliopathy, and/or severe abdominal discomfort. The surgical technique consisted in interposition of a free venous graft or of a prosthetic graft between the superior mesenteric vein and the Rex recess of the left portal vein.

RESULTS

Median operative time was 500 min (range 300-730). Median follow-up duration was 22 months (range 2-169). One patient died due to hemorrhagic shock following percutaneous transluminal intervention for early graft thrombosis. Major morbidity, defined as Clavien-Dindo score ≥ III, was 35.7% (5/14). Shunt patency at last follow-up was 64.3% (9/14): 85.7% (6/7) of pure venous grafts and only 42.9% (3/7) of prosthetic graft. Symptom relief was achieved in 85.7% (12/14) who became asymptomatic after MRB.

CONCLUSIONS

Adult EHPVO represents a difficult clinical condition that leads to severely compromised quality of life and possible life-threatening complications. In such patients, MRB represents the only and last resort to restore physiological portal vein flow. Although successful in a majority of patients, this procedure is associated with major morbidity and mortality and should be done in tertiary centers experienced with vascular liver surgery to get the best results.

Graft type for superior mesenteric and portal vein reconstruction in pancreatic surgery - A systematic review

BACKGROUND

Contemporary practice for superior mesenteric/portal vein (SMV-PV) reconstruction during pancreatectomy with vein resection involves biological (autograft, allograft, xenograft) or synthetic grafts as a conduit or patch. The aim of this study was to systematically review the safety and feasibility of the different grafts used for SMV-PV reconstruction.

METHODS

A systematic search was performed in PubMed and Embase according to the PRISMA guidelines (January 2000-March 2020). Studies reporting on ≥ 5 patients undergoing reconstruction of the SMV-PV with grafts during pancreatectomy were included. Primary outcome was rate of graft thrombosis.

RESULTS

Thirty-four studies with 603 patients were included. Four graft types were identified (autologous vein, autologous parietal peritoneum/falciform ligament, allogeneic cadaveric vein/artery, synthetic grafts). Early and overall graft thrombosis rate was 7.5% and 22.2% for synthetic graft, 5.6% and 11.7% for autologous vein graft, 6.7% and 8.9% for autologous parietal peritoneum/falciform ligament, and 2.5% and 6.2% for allograft. Donor site complications were reported for harvesting of the femoral, saphenous, and external iliac vein. No cases of graft infection were reported for synthetic grafts.

CONCLUSION

In selected patients, autologous, allogenic or synthetic grafts for SMV-PV reconstruction are safe and feasible. Synthetic grafts seems to have a higher incidence of graft thrombosis.

Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy

BACKGROUND AND PURPOSE

Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy.

METHODS

Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed.

RESULTS

The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy.

CONCLUSIONS

Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.

Successful Use of the Recanalized Remnant Umbilical Vein as a Patch Graft for Venous Reconstruction in Abdominal Surgery

Various approaches have been described for the reconstruction of the portal vein (PV), superior mesenteric vein (SMV), and the inferior vena cava (IVC). We present the use of the recanalized remnant umbilical vein in various settings including transplantation, major liver resection, and pancreatic surgery. We retrospectively analyzed four cases, in which a recanalized remnant umbilical vein was used for vascular reconstruction. The graft harvesting, size of the graft, technique of application, and short-term results of vascular patency were studied. A recanalized umbilical vein was successfully harvested from the ligamentum teres hepatis in all patients with 5 cm (median, range 3-7 cm) in length and 1.3 cm (median, range 1.0-1.8 cm) in width. The preparation of the vein was technically feasible and took no more than 5 min in each patient. All grafts were used as a patch for venous reconstruction. In three cases, the graft was used for the reconstruction of the PV or SMV. In one patient, the graft was used to repair a large defect of the IVC. All vascular reconstructions were considered as successful as no bleeding or thrombosis was observed postoperatively. The remnant umbilical vein is a reliable native autologous graft. We found that it is feasible to use this graft as a patch for the reconstruction of the IVC, PV, and SMV.

Umbilical cord tissue cryopreservation: a short review

In this review we present current evidence on the possibility of umbilical cord tissue cryopreservation for subsequent clinical use. Protocols for obtaining umbilical cord-derived vessels, Wharton’s jelly-based grafts, multipotent stromal cells, and other biomedical products from cryopreserved umbilical cords are highlighted, and their prospective clinical applications are discussed. Examination of recent literature indicates we should expect high demand for cryopreservation of umbilical cord tissues in the near future.

Hemispheric Outflow Reconstruction With Autologous Umbilical Vein in Living Donor Liver Transplantation

A 44-year-old man with hepatitis C virus-related cirrhosis underwent living donor liver transplantation (LDLT). The donor was his identical twin elder brother. On computed tomography, the markedly dilated umbilical vein was observed as a hepatofugal collateral. An extended left liver graft with the caudate lobe was harvested in a conventional manner. One orifice outflow reconstruction was performed by using an umbilical vein, which was extracted from the recipient. This vein-flap sheet was sutured to the outflow orifice of the liver graft in a two-thirds circle on the ventral side. One wide outflow orifice with a 90-mm vein umbilical-vein flap on the ventral wall of outflow was created. Excellent triphasic waveforms and velocities were demonstrated on postoperative Doppler ultrasonography. The post-transplant course was uneventful, with no need for immunosuppressants, and the patient was discharged without any complications on postoperative day 27. The volume of left liver increased from 406 cm3 to 1372 cm3 during the first 6 weeks after transplantation.

Portal vein thrombosis after reconstruction in 270 consecutive patients with portal vein resections in hepatopancreatobiliary (HPB) surgery

BACKGROUNDS

This study was aimed to evaluate the occurrence of portal vein thrombosis after portal vein reconstruction.

METHODS

The portal veins were repaired with venorrhaphy, end-to-end, patch graft, and segmental graft in consecutive 270 patients undergoing hepato-pancreto-biliary (HPB) surgery.

RESULTS

Portal vein thrombosis was encountered in 20 of 163 of end-to-end, 2 of 56 of venorrhaphy, and 2 of 5 of patch graft groups, as compared with 0 of 46 of segmental graft group (p < 0.05, N.S., p < 0001, respectively). Portal vein thrombosis occurred more frequently after hepatectomy than after pancreatectomy (p < 0.0001). The restoration of portal vein blood flow was more sufficiently achieved in the early re-operation within 3 days after surgery than in the late re-operation over 5 days after surgery (p < 0.05).

CONCLUSIONS

The segmental graft might have to be more preferred in the portal vein reconstruction. The revision surgery for portal vein thrombosis should be performed within 3 days after surgery.

Usefulness of a recanalized umbilical vein for vascular reconstruction in pediatric hepatic surgery

PURPOSE

Pediatric surgeons currently engage in various abdominal vascular surgeries, which sometimes require vascular conduits or grafts. Herein, we report our experience with patients undergoing vascular reconstruction using a recanalized umbilical vein (rUV) and their long-term outcome.

METHOD

Five patients with extrahepatic portal vein obstruction (EHPVO) underwent mesenterico-/porto-left portal vein (PV) bypass surgery using a short rUV conduit with an interposition vein graft. A sixth neonate with a huge hepatic tumor underwent PV reconstruction with anastomosis of rUV to the proximal PV stump following right hepatectomy with partial PV resection. A seventh patient underwent living donor liver transplantation for recurrent hepatoblastoma. The hepatic inferior vena cava (IVC) was resected because of tumor involvement and reconstructed by transposition of the infrahepatic IVC and interposition of rUV obtained from the donor liver graft.

RESULTS

Sufficient flow through rUV was achieved and maintained in all patients without any complications during follow-up (0.7-6.9 years). Esophageal varices, splenomegaly, and other laboratory test abnormalities because of portal hypertension disappeared after surgery in patients with EHPVO.

CONCLUSION

Our experience confirmed the usefulness and long-term patency of rUV as an entry to the intrahepatic PV and as a free vascular graft to reconstruct PV or IVC.

Catheter-directed thrombolysis through the operatively recanalized umbilical vein for acute extensive portal vein thrombosis: report of a case

Acute portal vein thrombosis is a rare but severe complication of intra-abdominal infection. It can be life-threatening, given the risk of developing liver abscess and subsequent liver failure. Various types of hereditary thrombophilia are known risk factors for acute portal vein thrombosis. In addition to surgical treatment and potent antibiotic therapy, systemic administration of anticoagulants and locoregional trans-catheter delivery of thrombolytic agents are known to be effective. We present a case report of acute portal vein thrombosis with pylephlebitis caused by acute appendicitis, successfully treated with catheter-directed thrombolysis through the operatively recanalized umbilical vein. The umbilical vein is a promising access route to the portal vein. Therefore, this procedure is an effective and preferred treatment option for portal septic thrombosis, particularly because it does not require puncture of the liver parenchyma or catheterization through an infected peritoneal cavity.