Renoportal anastomosis in right lobe living donor liver transplantation: report of a case

End-stage liver disease is often accompanied by thrombosis of the portal vein and the formation of splanchnic collateral vessels. Successful liver transplantation in such situations is more likely if the surgeon uses a strategy to establish a graft inflow. A 59-year-old male with a decompensated liver secondary to idiopathic portal hypertension underwent living donor liver transplantation (LDLT) using a right lobe liver graft donated from his son. His portal venous trunk was atrophied and a splenorenal shunt drained the mesenteric venous flow into the systemic circulation. LDLT was performed with renoportal anastomosis (RPA) using his right internal jugular vein as an interposed venous graft, without dissecting the collateral vessels. Although he developed temporary functional hyperbilirubinemia, he was discharged from the hospital 23 days after LDLT. This case suggests that RPA is a useful technique to manage patients with an obstructed portal vein and a splenorenal shunt.     

Successful Living-Donor Liver Transplantation With Intraoperative Endovascular Recanalization via Transsplenic Access in a Recipient With Grade III Portal Vein Thrombosis: A Case Report

Extensive portosplenomesenteric thrombosis is regarded as a relative contraindication to liver transplantation because of the complexity of the surgical procedure. This report describes a case of living-donor liver transplantation (LDLT) for a patient with extensive portosplenomesenteric thrombosis, in whom portal flow was successfully restored by intraoperative transplenic portal vein and superior mesenteric vein stenting after surgical thrombectomy. The patient’s liver function remained normal with a patent portal vein stent 6 months after LDLT, and Doppler ultrasonography demonstrated a normal wave form for portal flow. To the best of our knowledge, this is the world’s first case of endovascular management of the portal vein via percutaneous transsplenic access during LDLT, demonstrating that transsplenic access can be an alternative approach without liver graft injury when the superior mesenteric vein branch and inferior mesenteric vein cannot be used as access routes.     

Ligation of huge spontaneous porto-systemic collaterals to avoid portal inflow steal in adult living donor liver transplantation: A case-report

IntroductionIn adult living donor liver transplantation (LDLT), maintenance of adequate portal inflow is essential for the graft regeneration. Portal inflow steal (PFS) may occur due to presence of huge spontaneous porto-systemic collaterals. A surgical procedure to increase the portal inflow is rarely necessary in adult LDLT.PresentationA 52 years male patient with end-stage liver disease due to chronic hepatitis C virus infection. Preoperative portography showed marked attenuated portal vein and its two main branches, patent tortuous splenic vein, multiple splenic hilar collaterals, and large lieno-renal collateral. He received a right hemi-liver graft from his nephew. Exploration revealed markedly cirrhotic liver, moderate splenomegaly with multiple collaterals and large lieno-renal collateral. Upon dissection of the hepato-duodenal ligament, a well-developed portal vein could be identified with a small mural thrombus.The recipient portal vein stump was anastomosed, in end to end fashion, to the graft portal vein. Doppler US showed reduced portal vein flow, so ligation of the huge lieno-renal collateral that allows steal of the portal inflow. After ligation of the lieno-renal collateral, improvement of the portal vein flow was observed in Doppler US.DiscussionThere is no accepted algorithm for managing spontaneous lieno-renal shunts before, during, or after liver transplantation, and evidence for efficacy of treatments remains limited. We report a case of surgical interruption of spontaneous huge porto-systemic collateral to prevent PFS during adult LDLT.ConclusionComplete interruption of large collateral vessels might be needed as a part of adult LDLT procedure to avoid devastating postoperative PFS.     

Living Donor Liver Transplantation with Left Liver Graft

Small-for-size syndrome in LDLT is associated with graft exposure to excessive portal perfusion. Prevention of graft overperfusion in LDLT can be achieved through intraoperative modulation of portal graft inflow. We report a successful LDLT utilising the left lobe with a GV/SLV of only 20%. A 43 year-old patient underwent to LDLT at our institution. During the anhepatic phase a porto-systemic shunt utilizing an interposition vein graft anastomosed between the right portal branch and the right hepatic vein was performed. After graft reperfusion splenectomy was also performed. Portal vein pressure, portal vein flow and hepatic artery flow were recorded. A decrease of portal vein pressure and flow was achieved, and the shunt was left in place. The recipient post-operative course was characterized by good graft function. Small-for-size syndrome by graft overperfusion can be successfully prevented by utilizing inflow modulation of the transplanted graft. This strategy can permit the use of left lobe in adult-to-adult living donor liver transplantation.     

Successful Treatment of a Patient With Diffuse Portosplenomesenteric Thrombosis Using a Pericholedochal Varix for Portal Flow Reconstruction During Deceased Donor Liver Transplantation: A Case Report

Portal vein thrombosis remains a challenging issue in liver transplantation. When thrombectomy is not feasible due to diffuse portosplenomesenteric thrombosis, other modalities are adapted such as the use of a jump graft or portal tributaries or even multivisceral transplantation. For patients with diffuse thrombosis of the splanchnic venous system, a large pericholedochal varix can be a useful vessel for providing splanchnic blood flow to the graft and for relieving portal hypertension. We report our experience of successfully treating a patient with diffuse portosplenomesenteric thrombosis using a pericholedochal varix for portal flow reconstruction during deceased donor liver transplantation and eventually preventing unnecessary multivisceral transplantation. A 56-year-old man diagnosed with liver cirrhosis due to hepatitis B underwent deceased donor liver transplantation due to refractory ascites. Preoperative imaging revealed diffuse portosplenomesenteric thrombosis with large amount of ascites. During the operation, dissection of the main portal vein was not possible due to the development of multiple large pericholedochal varices and cavernous change of the main portal vein. After outflow reconstruction, portal inflow was restored by anastomosing the graft portal vein to a large pericholedochal varix. Postoperatively, although abdominal computed tomography scan showed stenosis of portal vein anastomosis site, liver function tests improved, and Doppler sonogram revealed no flow disturbance. During follow-up, the patient repeatedly developed hydrothorax and ascites. In addition, stenosis of the portal vein anastomosis and thrombosis of the portomesenteric system still remained. The patient underwent transhepatic portal vein stent insertion. After portal vein stent insertion, hydrothorax and ascites improved and the extent of thrombosis of the portomesenteric system decreased without anticoagulation therapy. In conclusion, enlarged pericholedochal varix in patients with totally obliterated splanchnic veins can be a source of useful inflow to restore portal flow and decrease the extent of thrombosis, thereby preventing unnecessary multivisceral transplantation.     

Impact of a Left-Lobe Graft Without Modulation of Portal Flow in Adult-to-Adult Living Donor Liver Transplantation

In adult-to-adult living donor liver transplantation (LDLT), left-lobe grafts can sometimes be small-for-size. Although attempts have been made to prevent graft overperfusion through modulation of portal inflow, the optimal portal venous circulation for a liver graft is still unclear. Hepatic hemodynamics were analyzed with reference to graft function and outcome in 19 consecutive adult-to-adult LDLTs using left-lobe grafts without modulation of graft portal inflow. Overall mean graft volume (GV) was 398 g, which was equivalent to 37.8% of the recipient standard liver volume (SV). The GV/SV ratio was less than 40% in 13 of the 19 recipients. Overall mean recipient portal vein flow (PVF) was much higher than the left PVF in the donors. The mean portal contribution to the graft was markedly increased to 89%. Average daily volume of ascites revealed a significant correlation with portal vein pressure, and not with PVF. When PVP exceeds 25 mmHg after transplantation, modulation of portal inflow might be required in order to improve the early postoperative outcome. Although the study population was small and contained several patients suffering from tumors or metabolic disease, all 19 patients made good progress and the 1-year graft and patient survival rate were 100%. A GV/SV ratio of less than 40% or PVF of more than 260 mL/min/100 g graft weight does not contraindicate transplantation, nor is it necessarily associated with a poor outcome. Left-lobe graft LDLT is still an important treatment option for adult patients.     

Risk factors for intraoperative portal vein thrombosis in pediatric living donor liver transplantation

Pathologic changes of the recipient native portal venous system may cause thrombosis of the portal vein, especially in pediatric living donor liver transplantation (LDLT). This study assessed the utility of Doppler ultrasound (US) for the detection of intraoperative portal vein occlusion and identification of predisposing risk factors in the recipients. Seventy-three pediatric recipients who underwent LDLT at Chang Gung Memorial Hospital, Taiwan, from 1994 to 2002 were included. Preoperative and intraoperative Doppler US evaluation of the portal vein was performed. Age, body weight, native liver disease, type of graft, graft recipient weight ratio (GRWR), type of portal anastomosis, portal velocity, portal venous size and presence of portosystemic shunt were analyzed for statistical significance of predisposing risk factors. Eight episodes of intraoperative portal vein thrombosis, with typical findings of absent Doppler flow in portal vein and prominent hepatic artery with a resistant index lower than 0.5 (p < 0.001), were detected during transplantation, which was then corrected by thrombectomy and re-anastomosis. Children age < or =1 yr (p = 0.025), weight < or =10 kg (p = 0.024), low portal flow < or =7 cm/s (p = 0.021), portal venous size < or =4 mm (p = 0.001), and GRWR >3 (p < 0.017) were all risk factors for intraoperative portal vein thrombosis. Doppler US is essential in the preoperative evaluation, early detection and monitoring of outcome of the portal vein in liver transplant.     

Successful Living Donor Liver Transplantation in Portomesenteric Thrombosis

Chronic portal vein thrombosis (PVT) is often considered a relative contraindication for living donor liver transplantation due to the risks involved and higher morbidity. In this report, we describe a surgical strategy for living donor liver transplant in patient with complete PVT using venovenous bypass from the inferior mesenteric vein (IMV) and then using a jump graft from the IMV for portal inflow into the graft. IMV is a potential source for portal inflow in orthotopic liver transplant.     

婴幼儿活体肝移植后的血流动力学变化及血管并发症

目的 探讨婴幼儿活体肝移植术后的血流动力学变化及血管并发症的发生情况.方法 应用彩色多普勒超声观测34例婴幼儿活体肝移植术后2个月内门静脉、肝动脉、肝左静脉最大流速及肝动脉阻力指数变化情况,并观察术后血管并发症的发生情况及其预后.结果 34例受者中,术后超声显示血管通畅者29例(85.3%,29/34),发生血管并发症5例(14.7%,5/34).29例血管通畅的患儿,术后第1天时门静脉最大流速(vmax)为(53.97±21.44)cm/s,肝动脉收缩期最大流速(PSV)为(52.88±17.87)cm/s,阻力指数(RI)为0.73±0.09,肝左静脉最大流速为(40.53±25.07)cm/s.与术后第1天比较,术后1周时门静脉vmax、肝动脉PSV、肝左静脉vmax及肝动脉RI的差异均无统计学意义(P＞0.05);术后2周时门静脉vmax为(44.26±17.43)cm/s,明显低于术后第1天(P＜0.05);术后2个月时门静脉vmax为(40.31±26.29)cm/s,肝动脉PSV为(41.50±8.67)cm/s,均明显低于术后第1天(P＜0.01,P＜0.05).5例血管并发症均发生在术后7 d内,其中肝动脉血栓形成3例(2例行取栓术,1例行溶栓治疗),门静脉血栓形成2例(1例行取栓术,1例行溶栓治疗),5例中3例死亡.结论 婴幼儿活体肝移植术后门静脉vmax和肝动脉PSV呈下降趋势;血管并发症发生时间早,发生率较高,活体肝移植术后7 d内至少应每天进行1次超声检查.     

Correlation Between Splenectomy and Portal Vein Complications in Living Donor Liver Transplantation

Objectives

In adults undergoing living donor liver transplantation (LDLT), the transplanted livers are partial grafts, and the portal venous pressure is higher than that observed with whole liver grafts. In patients undergoing LDLT concomitant with splenomegaly, portal venous flow is often diverted to collateral vessels, leading to a high risk of portal vein thrombosis. In such cases, occlusion of the collateral veins is important; however, complete occlusion of all collaterals without blocking the blood flow through the splenic artery causes portal hypertension and liver failure. We aimed to examine the effect of performing a splenectomy concomitant with LDLT to reduce portal vein complications.

亲属活体供肝移植治疗儿童终末期肝病六例

目的 探讨亲属活体供肝移植(LDLT)治疗儿童终末期肝病的效果,并总结治疗经验.方法 2005年9月至2007年1月对6例终末期肝病患儿进行了LDLT.6例患者中,原发病为肝内外胆管弥漫性囊性扩张症Ⅳ型伴肝硬化1例、肝豆状核变性2例、门静脉海绵样变性3例;供者为患儿的母亲3例、父亲2例及舅父1例,分别切取供者的右半肝1例和左半肝5例作为供肝;在切除受者全部病肝和保留下腔静脉后,对受者施行部分供肝的原位肝移植.术后依据供、受者的临床表现、血液学指标和影像学检查,对活体供肝移植的治疗效果进行评价.结果 术后对供、受者随访了6～21个月.6例供者均健康存活,未发生并发症.6例受者中,1例于术后第4天死于门静脉血栓形成,1例于术后5个月时死于肝内静脉血栓形成,其余4例均长期健康存活.结论 亲属活体供肝移植是治疗儿童终末期肝病的有效方法.术前进行仔细的供、受者选择和完善的影像学检查,术中应用精确的手术技术,术后给予严格的管理是儿童LDLT成功的关键.     

Caval inflow to the graft: a successful way to overcome diffuse portal system thrombosis in liver transplantation

Portal vein thrombosis was considered to be a major contraindication to liver transplantation before the introduction of vessel grafts from the recipient's area of confluence of the splenic and superior mesenteric veins, behind the neck of the pancreas, to the graft's portal vein. Refinement in surgical technique has given rise to a large number of possibilities to overcome portal vein thrombosis in OLT recipients, ranging from portal vein thrombectomy to several different venous graft jump reconstructions. All these reconstructions require the presence of a patent vein of the portal system. When neither splanchnic veins nor sufficiently large venous collaterals are available, liver transplantation has been considered impossible. Salvage solutions include arterialization of the portal vein with the associated risk of liver damage in the longterm, a combined liver and bowel transplantation has been proposed but not yet reported (and in any case the results of combined liver and bowel transplants are not as good as those of liver transplantation alone) and finally the use of blood inflow from the inferior vena cava as first reported by Tzakis and coworkers. Portal flow from the inferior vena cava may be performed as a last resort. Although the consequences of severe pretransplantation portal hypertension remain and should be treated before, during, and after transplantation, liver function is normal in the short and midterm. With this new procedure, diffuse portal vein thrombosis is no longer an absolute contraindication to liver transplantation. But this needs to be confirmed in light of further experience and longterm followup.     

A selective approach to preexisting portal vein thrombosis in patients undergoing liver transplantation.

Splanchnic venous inflow is considered mandatory to ensure graft survival after liver transplantation. Over a 68-month period, we performed 570 liver transplants in 495 patients. Portal vein thrombosis was present in 16 patients. At transplant, the extent of the occlusion included portal vein alone (n = 4), portal including confluence of the splenic and superior mesenteric veins (n = 8), portal, splenic, and distal superior mesenteric veins (n = 2), and the entire portal vein, splenic vein, and superior mesenteric vein (n = 2). The operative approach included thrombectomy alone (n = 5), anastomosis at the confluence of the splenic and superior mesenteric splenic veins (n = 8), and extra-anatomic venous reconstruction (n = 3). The mean operative blood loss was 22 +/- 22 units, and the mean operative time was 9.7 +/- 4.8 hours. The 1-year actuarial survival rate was 81%, with a mean follow-up of 12.5 months. In summary, with a selective approach and the use of innovative forms of splanchnic venous inflow, portal vein thrombosis is no longer a contraindication to liver transplantation.     

Could the use of interposition grafts for arterial reconstruction be avoided by more caudate graft placement in living donor liver transplantation?

One of the major challenges in living donor liver transplantation (LDLT) is short and small vessels (particularly the hepatic artery), particularly in segmental liver grafts from living donors. In the present study we report an alternative surgical technique that avoids interpositional vessel grafts or tension on the connection by anastomizing the allograft hepatic vein to the recipient inferior vena cava in a more caudate location. From March 2000 to January 2003, 28 patients (11 women/17 men) underwent 28 LDLT. Until June 2001, the preferred technique for hepatic vein anastomosis was end-to-end anastomosis between the allograft hepatic vein and the recipient hepatic vein (HV-HV) (n = 10). Thereafter an end-to-side anastomosis was performed between allograft hepatic vein and recipient inferior vena cava (HV-IVC) (n = 18). The level of venotomy on the recipient vena cava was decided according to the pre-anastomotic placement of the allograft in the recipient hepatectomy site with sufficient width to have an hepatic artery anastomosis without tension or need for an interposition graft during hepatic artery and portal vein anastomoses. Except the right lobe allograft with anterior and posterior portal branches, all portal and hepatic artery anastomoses were constructed without an interposition graft or tension in the HV-IVC group. Only one hepatic artery thrombosis developed in the HV-IVC group. As a result, this technique may avoid both hepatic artery thrombosis and the use of interposition grafts in living donor liver transplantation.     

Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis

Kim S‐J, Kim D‐G, Park J‐H, Moon I‐S, Lee M‐D, Kim J‐I, Yoon Y‐C, Yoo Y‐K. Clinical analysis of living donor liver transplantation in patients with portal vein thrombosis.
Clin Transplant 2011: 25: 111–118. © 2010 John Wiley & Sons A/S. Abstract: The aim of this study was to improve outcomes in living donor liver transplantation (LDLT) patients with portal vein thrombosis (PVT). Of 246 adult patients who underwent LDLT with a right lobe graft between January 2000 and May 2007, PVT was diagnosed in 50 patients (20.3%), who were further subdivided into partial (n = 39, 78%) and complete (n = 11, 22%) types. Patients with PVT, especially complete PVT, showed high incidences of variceal bleeding (p = 0.021), operative RBC transfusion (p < 0.046) and a post‐transplantation complications related to bleeding (p = 0.058). We also classified PVT according to its location and the presence of collaterals: type I (n = 41, 82%): PVT localized above the confluence of the splenic and superior mesenteric veins (SMV); type II (n = 7, 14%): PVT extending below the confluence with a patent distal SMV; type III (n = 2, 4%): complete portal vein and SMV thrombosis except for a coronary vein. LDLT could be safely undertaken in patients with PVT without increased mortality. In our type II and III PVT, when thrombectomy fails, jump grafting using a cryopreserved vessel may serve as a reliable alternative method to restore portal flow.     

Single center experience of 39 patients with preoperative portal vein thrombosis among 404 adult living donor liver transplantations.

Living donor liver transplantation (LDLT) for patients with portal vein thrombosis (PVT) involves technical difficulty. The aim of this research was to analyze their preoperative diagnosis of PVT, operative procedures, and postoperative courses of patients with preoperative PVT. Thirty-nine patients of 404 adult patients (9.7%) undergoing LDLT in our hospital from 1996 June to 2004 December had PVT at their transplantation. Twenty-nine patients had intractable ascites, 21 had gastrointestinal bleeding, and 18 had encephalopathy. The thrombus was located in the portal trunk in 23, in the portal trunk and superior mesenteric vein (SMV) in 7, and developed into the SMV and the splenic vein in 8. The occlusive grade was partial in 29, and complete in 10 patients. The thrombus was removed by a simple technique, and eversion and/or incision technique, or total removal of the portal vein (PV). The PV was reconstructed with the thrombectomized native PV, with an interposed vein graft, or porto-caval hemitransposition. Advanced PVT had a significant impact on blood loss and hospital mortality. Three out of 10 patients with residual PVT required radiological and/or surgical intervention after transplantation. In conclusion, thorough planning is essential for a successful LDLT outcome for patients with preexisting PVT.     

Left lobe adult-to-adult living donor liver transplantation: Should portal inflow modulation be added?

Recently, the successful application of portal inflow modulation has led to renewed interest in the use of left lobe grafts in adult-to-adult living donor liver transplantation (LDLT). However, data on the hepatic hemodynamics supporting portal inflow modulation are limited, and the optimal portal circulation for a liver graft is still unclear. We analyzed 42 consecutive adult-to-adult left lobe LDLT cases without splenectomy or a portocaval shunt. The mean actual graft volume (GV)/recipient standard liver volume (SLV) ratio was 39.8% ± 5.7% (median = 38.9%, range = 26.1%-54.0%). The actual GV/SLV ratio was less than 40% in 24 of the 42 cases, and the actual graft-to-recipient weight ratio was less than 0.8% in 17 of the 42 recipients. The mean portal vein pressure (PVP) was 23.9 ± 7.6 mm Hg (median = 23.5 mm Hg, range = 9-38 mm Hg) before transplantation and 21.5 ± 3.6 mm Hg (median = 22 mm Hg, range = 14-27 mm Hg) after graft implantation. The mean portal pressure gradient (PVP - central venous pressure) was 14.5 ± 6.8 mm Hg (median = 13.5 mm Hg, range = 3-26 mm Hg) before transplantation and 12.4 ± 4.4 mm Hg (median = 13 mm Hg, range = 1-21 mm Hg) after graft implantation. The mean posttransplant portal vein flow was 301 ± 167 mL/minute/100 g of liver in the 38 recipients for whom it was measured. None of the recipients developed small-for-size syndrome, and all were discharged from the hospital despite portal hyperperfusion. The overall 1-, 3-, and 5-year patient and graft survival rates were 100%, 97%, and 91%, respectively. In conclusion, LDLT with a left liver graft without splenectomy or a portocaval shunt yields good long-term results for adult patients with a minimal donor burden.     

Thrombosis Confined to the Portal Vein Is Not a Contraindication for Living Donor Liver Transplantation

BACKGROUND: There is a lack of agreement regarding preexisting portal vein thrombosis (PVT) in patients undergoing living donor liver transplantation (LDLT). We report the results of a single-center study to determine the impact of PVT on outcomes of adult LDLT recipients. METHODS: Of 133 cases of adult LDLT performed between January 2000 and December 2004, a thrombectomy was performed on 22 patients (16.5%) with PVT during the transplant procedure. One hundred eleven patients without PVT (group 1) were compared with those with a thrombosis confined to the portal vein (group 2; n = 15) and patients with the thrombosis beyond the portal vein (group 3; n = 7). RESULTS: The sensitivities of Doppler ultrasound and CT in detecting PVT were 50 and 63.6%. A prior history of variceal bleeding (OR = 10.6, p = 0.002) and surgical shunt surgery (OR = 28.1, p = 0.044) were found to be an independent risk factors for PVT. The rate of postoperative PVT was significantly higher in patients with PVT than in those without (18.2 vs. 2.7%; p = 0.014). In particular, the rethrombosis rate in group 3 was 28.6%. The actuarial 3-year patient survival rate in PVT patients (73.6%) was similar to that of the non-PVT patients (85.3%; p = 0.351). However, the actuarial 3-year patient survival rate in group 3 was 38.1%, which was significantly lower than that in groups 1 and 2 (p = 0.006). CONCLUSION: A thrombosis confined to the portal vein per se should not be considered a contraindication for LDLT.     

Portal revascularization in the setting of cavernous transformation through a paracholedocal vein: a case report

Diffuse thrombosis of the entire portal system (PVT) and cavernomatous transformation of the portal vein (CTPV) represents a demanding challenge in liver transplantation. We present the case of a patient with nodular regenerative hyperplasia and recurrent episodes of type B hepatic encephalopathy concomitant with PVT as well as CTPV, successfully treated with orthotopic liver transplantation. The portal inflow to the graft was carried out through the confluence of 2 thin paracholedochal varicose veins, obtaining good early graft function and recovery of the encephalopatic episodes. This alternative should be kept in mind as an option to assure hepatopetal splanchnic flow in those cases of diffuse thrombosis and cavernomatous transformation of portal vein.     

Posterior cavoplasty: a new approach to avoid venous outflow obstruction and symptoms for small-for-size syndrome in right lobe living donor liver transplantation

Purpose  

A common and serious problem after living donor liver transplantation (LDLT) of small grafts is small-for-size syndrome (SFSS). Although hyperdynamic portal inflow and portal hypertension are cornerstones in the development of SFSS, inadequate outflow may aggravate SFSS. Therefore, enlargement of the portal outflow tract by incision of the anterior rim of the orifice of the right hepatic vein (RHV) has been advocated for right lobe LDLT. But backwards tilt of a small graft into a large abdominal cavity may lead to a choking of the otherwise large anastomosis and thus we propose posterior enlargement of the orifice of the RHV.