The use of Dacron graft for cavo-cavostomy in orthotopic liver transplantation

The end-to-end "interposition" technique and end-to-side "piggyback" technique are standard approaches to in situ anastomosis during orthotopic liver transplantation. We demonstrate that anastomosis of liver allograft to a Dacron vena cava graft can be a feasible solution if traditional anastomoses cannot be used. A 55-year-old man with end-stage liver failure from alcoholic cirrhosis underwent orthotopic liver transplantation; however, an intraoperative complication during recipient hepatectomy rendered the native vena cava unsalvageable. In addition, the donor vena cava was too short to bridge the caval defect for interposition. We therefore used Dacron for an in situ graft to span the gap, with subsequent anastomosis of the allograft to the prosthetic graft in piggyback fashion. The patient did well postoperatively; his only major complication was late anastomotic stenosis, which was treated successfully with balloon dilatation. Unfortunately the patient became recidivous and expired ten months posttransplant, despite indications of satisfactory allograft function.     

Advantages of inferior vena caval flow preservation in combined transplantation of the liver and heart

Only a few cases of combined liver and heart transplantation have been reported in the literature, and no standard surgical procedure has yet been established. We report the successful transplantation of both liver and heart in a 28-year-old patient suffering from homozygous beta-thalassemia. We used Belghiti's technique of inferior vena caval flow preservation for liver transplantation, which avoids inferior vena cava occlusion by a side-to-side caval anastomosis. Applied to combined liver and heart transplantation, preservation of caval flow during liver transplantation may allow early discontinuation of cardiopulmonary bypass and, thus, minimize the general consequences of prolonged bypass. Received: 21 May 1996 Received after revision: 11 September 1996 Accepted: 23 September 1996     

Analysis of the complications of the piggy-back technique in 1,112 liver transplants.

BACKGROUND: The "piggy-back" technique has gained acceptance in adult orthotopic liver transplantation during the last few years, especially in European countries. At the moment, however, there is controversy over advantages or specific complications (suprahepatic thrombosis or narrowing, etc.) related to this surgical technique. The aim of this study is to know of the immediate per-and postoperative morbidity and mortality rates in 1112 orthotopic liver transplantations performed with a vena cava preservation technique. METHODS: All liver transplant units in Spain were sent a questionnaire on retrohepatic vena cava preservation during orthotopic liver transplantation. The number of orthotopic liver transplantations that had been performed in the seven centers that answered the questionnaire, because the beginning of the program, was 1674, with the vena cava preservation technique used in 1112. RESULTS: Twenty-eight patients (2.5%) had intraoperative complications related to the vena cava preservation technique, which were treated during the operation. Eleven patients (1%) had early postoperative complications (first week), the most frequent (nine cases) being an acute Budd-Chiari syndrome in the first 48 hr. Three patients developed symptoms of massive ascites between 2 and 3 months (late postoperative complications), with patency of the retrohepatic cava verified by cavography. A hemodynamic study revealed a hyperpressure at the suprahepatic veins. This chronic Budd-Chiari syndrome was controlled in all patients with diuretics. Only six patients (0.5%) died as a result of complications related to the "piggy-back" technique. These complications were more frequent when venous reconstruction was done using two suprahepatic veins than when the three veins were used (P<0.001). CONCLUSIONS: The vena cava preservation technique can be used routinely in orthotopic liver transplantation because it is safe and efficient and involves few surgical complications especially if for venous reconstruction we use the patch obtained by joining the three suprahepatic veins.     

Hanging of the Hepatic Veins Septa: A Safe Control Prior and During Outflow Anastomosis in Liver Transplantation

Inferior vena cava (IVC) preservation during orthotopic liver transplantation (OLT) is known as the “piggyback” technique. The end-to-side anastomosis is constructed between the graft's IVC and recipient's hepatic veins using a Satinsky side clamp applied in a transverse position. To stabilize the large Satinsky clamp and preserve a sufficient vascular stump after hepatectomy and before graft implantation, we propose a technical innovation consisting of hanging the septa between the left and middle hepatic vein and between the middle and right hepatic vein using 2 tapes. This technique showed some advantages when performing the caval outflow anastomosis, representing a further technical refinement of the piggyback end-to-side technique for the implantation on the 3 hepatic veins. From November 2001 to September 2012, we performed 272 consecutive OLT at our institution with the piggyback technique using the hanging of the hepatic veins septa in all cases. In conclusion, the hanging of the 3 hepatic veins septa presented in this study represents a simple, safe and reproducible technique for the outflow anastomosis using the piggyback technique.     

Side-to-side cavo-cavostomy: a useful aid in “complicated” piggy-back liver transplantation

Piggy-back liver transplantation is a useful technical variant of orthotopic liver transplantation. Its success can, however, be compromised by severe stenosis or obstruction of the recipient's inferior vena cava at the level of the anastomosis. A technique is described — side-to-side cavocavostomy — to resolve this difficult intraoperative situation.     

Side-to-Side Cavocavostomy in Adult Piggyback Liver Transplantation

Objective

Our objective was to perform a retrospective study that described the anastomosis technique as well as the complications of side-to-side cavo-caval reconstruction.

Patients and Methods

From June 1998 to April 2011, we performed 284 liver transplantations including 10 adults with live donor organs. In all cases but 2 (272), cavo-caval reconstruction was performed using side-to-side cavo-caval (STSCC) anastomosis. In 19 cases (6.9%), we also carried out an end-to-side temporary porto-caval shunt (TPCS). In 17 cases (6.2%) the technique was performed for retransplantation.

Results

STSCC anastomosis was technically feasible in all but 2 cases, regardless of the recipient's vena cava, anatomic factors, or graft size. Mean operative time for the STSCC was 13 minutes (range, 6-25). Routine Doppler ultrasonography was performed intraoperatively at the end of the surgery. There was no case of cava stump thrombosis. Complications associated with this technique were limited to 2 patients. One complication was torsion due to donor graft/recipient mismatch, which was successfully treated surgically by falciform ligament fixation. The second complication was only evident by sinusoidal congestion and was managed nonoperatively. Seventeen cases were uneventful for retransplant recipients.

Conclusions

STSCC during piggyback liver transplantation is safe and can be performed in the retransplantation setting, with a low incidence of venous outflow obstruction that can be associated with the traditional piggyback technique. Our data suggest that donor graft to recipient mismatch is not an absolute contraindication when proper body size match is considered. A wide anastomosis with typical recipient hepatic vein inclusion is warranted with routine postanastomotic Doppler ultrasonography.     

Successful liver transplantation in an adult residual atrial septal defect and left-to-right shunt

A case of orthotopic liver transplantation performed in an adult, presenting postviral C cirrhosis and a residual atrial septal defect, is reported. This defect was responsible for a left-to-right shunt and moderate systolic pulmonary hypertension. Liver transplantation was done using an inferior vena cava preservation technique with a latero-lateral cavo-caval anastomosis and without veno-venous bypass in order to minimally interfere with the haemodynamic condition. This case report shows that adaptation of surgical technique may allow successful liver transplantation in cases of haemodynamically significant atrial septal defects.     

Endovascular treatment of hepatic venous outflow obstruction after piggyback technique liver transplantation.

BACKGROUND: The piggyback technique of orthotopic liver transplantation is an attractive alternative that preserves the recipient inferior vena cava and allows uninterrupted venous blood return during the anhepatic phase. As with other transplantation techniques, the vascular anastomoses required by the piggyback technique can develop strictures. METHODS: Review of records of 264 piggyback transplantations revealed two cases of delayed-onset hepatic venous obstruction from anastomotic strictures. Both patients also had symptoms of inferior vena cava obstruction, with azotemia and lower extremity edema. Both patients were treated percutaneously with balloon-expandable stents. RESULTS: Rapid, dramatic resolution of symptoms was achieved in both patients. Patients remain completely asymptomatic at 39 and 3 months of follow-up. CONCLUSIONS: Hepatic venous anastomotic strictures in recipients of piggyback technique transplants are a very uncommon complication. They may be easily and effectively treated by minimally invasive endovascular intervention.     

Orthotopic liver transplantation with preservation of portocaval flow compared with venovenous bypass

Conventional liver transplantation requires cross-clamping of the hepatic pedicle and inferior vena cava, leading to severe hemodynamic and metabolic disturbances, usually attenuated by the use of venovenous bypass. A more recent surgical technique, piggyback with temporary portocaval shunting, preserves both caval and portal blood flows. The aim of this study was to compare the two methods prospectively. Forty- four patients with chronic liver disease were studied. Local anatomic conditions guided the surgeon to choose the easiest way to remove the native liver. Anesthetic management was standardized. Hemodynamic and metabolic changes were assessed by use of routine tests at specific periods. Graft function was evaluated by measurement of aminotransferases and monoethylglycinexylidide (MEGX) test 12, 24, 48, and 72 hours postoperatively. Conventional liver transplantation with venovenous bypass was performed in 26 patients, and the piggyback with temporary portocaval shunting was performed in 15 patients. ANOVA showed that cardiac output and systemic oxygen delivery were better maintained before revascularization in the piggyback group. Metabolic changes were comparable, and hyperfibrinolytic activity was detected in both groups. Graft function was comparable and satisfactory within the 3 first postoperative days. Piggyback with temporary portocaval shunting provided better intraoperative hemodynamics and tissue oxygenation than liver transplantation with venovenous bypass. (Liver Transpl Surg 1997 Sep;3(5):518-25)     

原位肝移植的常用手术方式及应用体会

目的探讨经典原位肝移植术、改良背驮式肝移植术、原位肝移植腔静脉成形术在临床应用中的利弊。方法对2001年10月至2004年5月实施的155例病人的159次肝移植术式进行回顾性分析，其中经典原位肝移植术94例，改良背驮式肝移植术48例（包括改良背驮＋术中门一腔静脉端侧吻合转流8例），原位肝移植腔静脉成形术17例；术中行血管架桥5例，其中因门静脉闭锁及栓塞行供肝门静脉与受体肠系膜上静脉间架桥2例，因动脉变异分支细小不能利用行供肝腹腔干与受体腹主动脉间架桥3例。159例次肝移植手术均未应用体外静脉转流技术。结果原位肝移植腔静脉成形术的手术时间、无肝期最短，术中失血输血量最少，其术中对循环和肾功能的影响与经典术式相仿。经典原位肝移植术与背驮式肝移植术相比流出道不畅发生率较低，总手术时间较短（平均少30min），但无肝期较长（平均长8min），术中及术后肾上腺出血发生率较高，对肾功能影响较大，三组术后ICU留置天数差异亦无显著性意义（P=0．542）。结论不同的肝脏移植术式各有其优缺点，术者的经验以及对术式的熟悉程度会影响手术方式的选择，从原则上讲，手术方式的选择应根据具体病情及术中情况而决定。     

Technique and results of biliary reconstruction using side-to-side choledochocholedochostomy in 300 orthotopic liver transplants.

OBJECTIVE: The authors evaluated the complication rate and outcome of side-to-side common bile duct anastomosis after human orthotopic liver transplantation. SUMMARY BACKGROUND DATA: Early and late biliary tract complications after orthotopic liver transplantation remain a serious problem, leading to increased morbidity and mortality. Commonly performed techniques are the end-to-end choledochocholedochostomy and the choledochojejunostomy. Both techniques are known to coincide with a high incidence of leakage and stenosis of the bile duct anastomosis. The side-to-side bile duct anastomosis has been shown experimentally to be superior to the end-to-end anastomosis. The authors present the results of 316 human liver transplants, in which a side-to-side choledochocholedochostomy was performed. METHODS: Biliary tract complications of 370 transplants in 340 patients were evaluated. Three hundred patients received primary liver transplants with side-to-side anastomosis of donor and recipient common bile duct. Thirty-two patients with biliary tract pathology received a bilioenteric anastomosis, and in eight patients, side-to-side anastomosis was not performed for various reasons. Clinical and laboratory investigations were carried out at prospectively fixed time points. X-ray cholangiography was performed routinely in all patients on postoperative days (PODs) 5 and 42. In patients with suspected papillary stenosis, endoscopic retrograde cholangioscopy and papillotomy were performed. RESULTS: One biliary leakage (0.3%) was observed within the early postoperative period (PODs 0 through 30) after liver transplantation. No stenosis of the common bile duct anastomosis was observed during this time. Late biliary stenosis occurred in two patients (0.6%). T tube-related complications were observed in 4 of 300 primary transplants (1.3%). Complications unrelated to the surgical technique, including papillary stenosis (5.7%) and ischemic-type biliary lesion (3.0%), which must be considered more serious in nature than complications of the anastomosis or T tube-related complications, were observed. Papillary stenosis led to frequent endoscopic interventions and retransplantations in 1.3%. CONCLUSIONS: Side-to-side common bile duct anastomosis represents a safe technique of bile duct reconstruction and leads to a low technical complication rate after human orthotopic liver transplantation. Ischemic-type biliary lesion evoked by preservation injury, arterial ischemia, cholestasis, and cholangitis may represent a new entity of biliary complication, which markedly increases the morbidity after human liver transplantation. Therefore, this complication should be the subject of further research.     

Polycystic Liver Disease and Liver Transplantation: Single-Institution Experience

Adult polycystic liver disease (PLD) can cause massive hepatomegaly leading to pain, caval obstruction, and hemorrhage. Many surgical techniques including aspiration, fenestration, and resection have been used to treat PLD. In addition to substantial morbidity and mortality, conservative surgery may have limited success, and palliation may be temporary. With improved results of liver transplantation, it has become the definitive treatment for PLD. We retrospectively reviewed our experience in patients with PLD between 1998 and 2007. Thirteen patients underwent liver only or liver-kidney transplantation. All surgical procedures were performed with preservation of the recipient inferior vena cava and without venovenous bypass (piggyback technique). Our patients experienced a high rate of perioperative morbidity. However, long-term patient and graft survival were excellent.     

Retransplantation of the liver after side-to-side caval anastomosis

Caval reconstruction in orthotopic liver transplantation is generally performed by two end-to-end anastomoses, using a portal and caval-axillary bypass to sustain hemodynamic stability. In the piggyback modification, the donor's suprahepatic inferior vena cava (IVC) is anastomosed end-to-side to the recipient's preserved IVC. We have used a recently described variant of the piggyback in 18 patients in whom both IVCs are anastomosed side-to-side. We report two patients who needed three retransplants after this reconstruction and conclude that regrafting can be performed in a quick and safe manner.     

大鼠原位肝移植制作过程中常见失败原因分析及处理策略

目的：分析大鼠位肝移植制作过程中常见失败原因及总结相应的处理策略。
方法：历时10个月,采用改良Kamada二袖套法制作大鼠原位肝移植模型150例。将每完成50例作为1个实验阶段,分早、中、后期3个阶段对失败原因进行分析,总结经验。
结果：大鼠原位肝移植常见失败原因在早期阶段主要以气胸（5.8%）,术中出血（10.6%）,无肝期过长（50.4%）为主;中、后期主要以肝上下腔静脉吻合失败（21.0%）,无肝期过长（20.6%）,门静脉及肝下下腔静脉袖套吻合失败（17.6%）,胆管重建失败（5.6%）为主。
结论：导致大鼠原位肝移植模型制作失败的原因较多,无肝期是影响成功与否的关键,及时地对失败原因进行分析总结并寻找合理的解决办法,有助于初学者熟练地掌握该技术。     

Recurrent portal hypertension after composite liver/small bowel transplantation

Late technical complications of composite liver/small bowel transplantation procedures are often complex and have not been well defined. Here we describe the unusual presentation and management of two cases of recurrent thrombocytopenia due to hypersplenism resulting from portacaval shunt stenosis. Both patients presented with portal hypertension late after composite liver/small bowel transplantation. One patient presented with recurrent bouts of upper gastrointestinal hemorrhage and was ultimately found to have a stenosis of her native portacaval shunt. After unsuccessful balloon dilatation of the anastomosis, a successful side-to-side distal splenorenal shunt was performed. The second patient presented with severe thrombocytopenia, the etiology of which was determined to be a short segment occlusion of the inferior vena cava between the native portacaval shunt and the piggyback outflow anastomosis of the liver graft. Total caval occlusion prevented balloon dilatation; the patient was relisted for transplantation but died of chronic rejection four months later. Recurrent portal hypertension is challenging in patients who have had combined liver/small bowel transplantation. Surgeons performing intestinal transplantation need to be increasingly aware of these possible late complications. (Liver Transpl 2002;8:639-642.)     

背驮式肝移植的技术改进(附一例报告)

目的 探讨更完善的背驮式肝移植术式。方法 保留受者的腔静脉、肝静脉全部结扎,在受者的下腔静脉上开一侧孔,将供肝腔静脉近端与受者的下腔静脉侧孔行端侧吻合,远端缝扎。术中测定受者各时相的血流动力学参数。结果 无肝期为５０例,整个手术历时８小时,术中失血２５００ｍｌ。术中血流动力学平稳。术后肝功能指标大部分恢复正常,胆汁引流量约２００ｍｌ／ｄ。术后第５８天因肾功能衰竭死亡。结论 本术式适合于良性终末期肝     

无肝期阻断下腔静脉对背驮式肝移植的影响

目的 探讨背驮式肝移植无肝期血流阻断方式的不同引起的再灌注损伤差异及无肝期时间的长短对机体的影响。方法 通过大鼠无肝期下腔静脉血流的阻断来建立相关模型,以血液指标的改变做为指标,结合光镜检查结果,了解机体损伤差异。结果 无肝期的延长及下腔静脉阻断可以加剧机体损伤。结论 背驮式肝移植无肝期可以短时间阻断或部分阻断下腔静脉。     

Bicaval anastomosis in a heart transplant recipient with left superior vena cava

We describe the surgical procedure of orthotopic heart transplantation (OHT) in a recipient with persistent left superior vena cava (LSVC) and isolated noncompaction of the left ventricle. The bicaval anastomosis technique was performed using and isolating his native coronary sinus to let the left superior vena cava drain into his own inferior vena cava through the native coronary sinus.     

Cross-clamping of the three hepatic veins in the piggyback technique is a safe and well tolerated procedure

Abstract A common stump of the three hepatic veins has always been used to fashion the upper vena cava anastomosis in 205 liver transplantations with the piggyback (PGB) technique performed in our Unit, to avoid outflow problems. The aim was to study the repercussion of lateral inferior vena cava (IVC) clamping on IVC flow and pressure as well as on systemic hemodynamics. We have studied 42 orthotopic liver transplantations performed with the PGB technique. Intraoperative IVC blood flow measurements by transit time ultrasonic volume flowmetry, IVC pressure, and systemic hemodynamics were taken before and after lateral IVC clamping. Graft outflow complications, stenosis or kinking of the upper vena cava anastomosis have not been found in any of the 205 PGB procedures. A significant decrease of IVC flow (23%) and cardiac out-put (12%) occurred after IVC clamping, whereas mean arterial and central venous pressures were not altered significantly, probably due to an increase (25%) of systemic vascular resistance. Only in one case was an almost total clamping of IVC needed. Venovenous bypass was not needed in any case. Renal perfusion pressure was adequate in all cases. We conclude that the use of a common stump of the three hepatic veins for upper vena cava anastomosis in the PGB technique is safe because any outflow problem of the graft is avoided and, at the same time, is well tolerated hemodynamically because most of the IVC flow is preserved.     

Suprahepatic venacavaplasty (cavaplasty) with retrohepatic cava extension in liver transplantation: experience with first 115 cases.

BACKGROUND: We first introduced the orthotopic liver transplantation utilizing cavaplasty technique in 1994. This paper describes the surgical technique and assesses the outcome of the cavaplasty OLT. METHODS: The cavaplasty procedure was used in 115 consecutive orthotopic liver transplantations, including six left lateral and two right lobe transplantations, between November 1994 and September 2000. Fifty-three (66.3%) transplantations required femoro-axillary veno-venous bypass in the initial 4 years, whereas only eight (22.9%) needed VB in the subsequent 2 years. Conversion to piggyback or standard technique was not necessary in any patient. RESULTS: Median results are as follows: operative time 4.5 hr, warm ischemia time 25 min, and blood transfused (packed red blood cells) 6 units. These findings did not differ between first transplantation and retransplantation. There were no perioperative deaths related to the cavaplasty technique. No hepatic venous outflow obstruction was observed, including living-related OLTs. No patient required postoperative hemodialysis for acute renal failure. The median intensive care and hospital stays were 2 days and 10 days, respectively. CONCLUSIONS: The cavaplasty technique requires no retrocaval, hepatic vein, or short hepatic vein dissection, and the inferior vena cava can be preserved, which provides advantages for hepatectomy and easy hemostasis, especially during retransplantation. The wide-open triangular caval anastomosis is easy to perform, allowing short implantation time and size matching and avoiding outflow obstruction. The short implantation time reduces the need for veno-venous bypass. Our experience indicates that the cavaplasty technique can be applied to all patients and is justified by minimal technical complications.