Surgical strategies to treat portal vein thrombosis during adult liver transplantation

BACKGROUND

The incidence of portal vein thrombosis (PVT) at the time of liver transplantation (LT) may be variable and underestimated. Therefore, preoperative diagnosis and stratification of its extension is so relevant for adequate surgical planning. Revascularization of the portal vein graft becomes essential for graft and patient survival after LT. Early stages of PVT may be managed with eversion thrombectomy and end-to-end anastomoses. However, severe PVT (grades 3 and 4) poses significant challenges for patients requiring LT, resulting in more complex surgeries and higher complication rates. To address these complexities, various surgical techniques have been developed, including collateral alternative vessel utilization, renoportal anastomoses, mesoportal jump graft placement, cavoportal hemitranspositions, portal vein arterialization, or even multivisceral transplantation.

PURPOSE

We herein describe the preoperative surgical planning as well as the different surgical strategies possible to treat portal vein thrombosis during LT.

CONCLUSION

A comprehensive preoperative evaluation of PVT is crucial for accurately assessing its extent and severity. This information is vital for proper surgical planning, which ultimately prepares both the surgeon and the patient for potentially complex procedures during LT. The surgical alternatives presented in this technical report offer promising solutions for treating PVT during LT, making it a viable option for selected patients.

Beneficial long term effect of a phosphodiesterase-5-inhibitor in cirrhotic portal hypertension: A case report with 8 years follow-up

Non-selective beta-blockers are the mainstay of medical therapy for portal hypertension in liver cirrhosis. Inhibitors of phosphodiesterase-5 (PDE-5-inhibitors) reduce portal pressure in the acute setting by > 10% which may suggest a long-term beneficial effect. Currently, there is no available data on long-term treatment of portal hypertension with PDE-5-inhibitors. This case of a patient with liver cirrhosis secondary to autoimmune liver disease with episodes of bleeding from esophageal varices is the first documented case in which a treatment with a PDE-5-inhibitor for eight years was monitored. In the acute setting, the PDE-5-inhibitor Vardenafil lowered portal pressure by 13%. The portal blood flow increased by 28% based on Doppler sonography and by 16% using MRI technique. As maintenance medication the PDE-5-inhibitor Tadalafil was used for eight consecutive years with comparable effects on portal pressure and portal blood flow. There were no recurrence of bleeding and no formation of new varices. Influencing the NO-pathway by the use of PDE-5 inhibitors may have long-term beneficial effects in compensated cirrhosis.

Re-establishment of hepatic blood flow by portal vein arterialization and its influence on liver hemodynamics in rats with obstructive jaundice

AIM: To investigate the liver hemodynamic changes after re-establishment of hepatic blood flow by portal vein arterialization in rats with obstructive jaundice.

METHODS: Forty rats were randomly divided into 4 groups (n = 10, for each group). The first group served as control, and the second group included the rats with 5-day obstructive jaundice. The rats in the third group underwent common bile duct reopening after 5-day obstructive jaundice, while received portal caval vein dissociation and common hepatic artery ligation. The rats in the fourth group underwent common bile duct reopening after 5-day obstructive jaundice, while received portal vein arterialization. The following indicators were observed for 1 month, including general condition, liver structure and function, hepatic blood flow, portal venous pressure and liver microvessels.

RESULTS: After common bile duct ligation for 5 days, the levels of T-BIL, D-BIL, ALT, AST and ALP were significantly increased (141.7 ± 10.6 vs 6.7 ± 2.1, 68.16 ± 7.6 vs 3.25 ± 1.7, 132 ± 22 vs 53 ± 8, 160 ± 38 vs 73 ± 16, 285 ± 60 vs 148 ± 41; all P< 0.01). After 5-day common bile duct ligation, reopening and portal vein arterialization for 1 month, the hepatic blood flow and portal venous pressure had no significant difference from those of normal controls. Cast specimens of blood vessels showed that hepatic sinusoids were slightly thicker and their filling was more obvious than normal. Although there was slight deformation, they were distributed around the central vein in a radial form.

CONCLUSION: Portal vein arterialization has no obvious influence on liver hemodynamics and microvessels. Liver function and structure can successfully restore to normal.