Living-donor liver transplantation with renoportal anastomosis for patients with large spontaneous splenorenal shunts

BACKGROUND: End-stage liver disease is often accompanied by large spontaneous splenorenal shunts and thrombosed portal vein. Renoportal anastomosis for spontaneous splenorenal shunts in living-donor liver transplantations is one of the solutions for the treatment of these patients. However, the long-term outcome, portal venous hemodynamics after liver transplantation, and the effects of altering the renal venous drainage remained unknown. METHODS: We performed three living-donor liver transplantations with renoportal anastomosis for the treatment of spontaneous splenorenal shunts between 1999 and 2004. We then evaluated the outcome of this procedure using short- and long-term follow-ups in which the postoperative graft function, renal function, radiological images and portal hemodynamics were examined. RESULTS: All three patients who underwent a living-donor liver transplantation with renoportal anastomosis are alive with normal graft function and a patent renoportal anastomosis. The portal hemodynamics were similar to those in conventional living-donor liver transplantation recipients, and had no harmful effect on allograft function. Left renal function returned to normal after the temporal impairment in two cases, and remained slightly impaired in one, although it was negligible clinically. CONCLUSIONS: Living-donor liver transplantation with renoportal anastomosis for the treatment of spontaneous splenorenal shunts in patients with end-stage liver disease is a life-saving and safe technique and should be discussed as a treatment option for patients with splenorenal shunts.     

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.     

Innovative techniques for and results of portal vein reconstruction in living-related liver transplantation

BACKGROUND: Portal vein reconstruction is a crucial factor affecting the outcome of a successful living-related liver transplantation. We describe here our experience with portal vein reconstruction in 314 cases of living-related liver transplantation with use of novel surgical modalities to enable the transplant surgeons to deal with any size mismatch between the donor's and recipient's portal veins. METHODS: Portal vein reconstruction was classified into 2 major groups, anastomosis without and with a vein graft. When there was no stenosis of the recipient portal vein and the diameter was the same, the portal trunk was used for anastomosis. When the diameter mismatch was minimal, branch patch anastomosis was feasible. When the recipient portal vein was significantly stenotic and the portal vein of the graft was long enough, we removed the stenotic trunk and constructed an anastomosis between the graft portal vein and the confluence of the recipient portal vein. When the graft portal vein was short, a vein graft was interposed. The vein patch technique was preferable when the diameter of the graft vein was not large enough for the interposition technique. RESULTS: Anastomosis without vein graft included trunk anastomosis (n = 156), branch patch anastomosis (n = 39), and confluence anastomosis (n = 22). Anastomosis with vein graft used the interposition technique (n = 77) and vein patch technique (n = 27). The origin of the grafts was mostly from the maternal left ovarian vein (70%) or the paternal inferior mesenteric vein (27%). Complications related to portal vein reconstruction occurred in 16 (5%) patients: portal vein thrombosis in 8, stenosis in 7, and fatal rupture in 1 patient. The incidence of complications was similar for all techniques except for confluence anastomosis. CONCLUSION: Our innovative techniques should be helpful for overcoming diameter or length mismatches in portal vein reconstruction in pediatric liver transplantation.     

Liver transplantation with renoportal anastomosis after distal splenorenal shunt

BACKGROUND: The distal splenorenal shunt (DSRS) is designed to maintain hepatopetal portal vein flow while decompressing gastroesophageal varices. However, over time, as the underlying liver disease progresses, the DSRS loses its selectivity. The most common method of addressing this issue during orthotopic liver transplantation is shunt ligation with or without splenectomy. Dismantling the shunt increases the complexity of the transplantation, and splenectomy may increase the risk of infection. HYPOTHESIS: Anastomosis of the donor portal vein to the left renal vein without dismantling the shunt is an effective method of portal vein reconstruction for patients with a patent DSRS. DESIGN: Retrospective analysis. SETTING: University-based teaching hospital, Miami, Fla. PATIENTS: Five liver transplant recipients with patent DSRS who received an orthotopic liver transplant between September 1996 and August 1999. INTERVENTIONS: The donor portal vein was anastomosed end-to-end to the left renal vein during liver transplantation. MAIN OUTCOME MEASURES: Perioperatve morbidity, portal vein flow by Doppler study, patient survival, and graft survival. RESULTS: In all patients, the graft liver reperfused promptly via flow through the left renal vein with adequate decompression of the bowel. Normal portal venous flow was demonstrated by intraoperative and postoperative Doppler ultrasound studies. At the mean follow-up of 16 months, 4 patients were alive with well-functioning grafts. CONCLUSIONS: This novel technique has the advantage of decreasing the complexity of the procedure, without requiring splenectomy, while securing adequate portal perfusion. Additionally, it can be applied without modifications in patients with portal vein thrombosis.     

Left renal vein ligation for large splenorenal shunt during liver transplantation

Adequate hepatopetal portal vein blood flow is obligatory to ensure proper liver function after liver transplantation. Large collateral veins as shunts impair portal vein flow and even cause hepatofugal blood flow and portal steal syndrome. In particular, splenorenal shunts in liver transplant recipients can lead to allograft dysfunction and possible allograft loss or hepatic encephalopathy. Restoration of portal flow through left renal vein ligation (LRVL) is a treatment option, which is much easier compared to splenectomy, renoportal anastomosis and shunt closure, but bears the risk of moderate and temporary impairment of renal function. In addition, a patent portal vein is mandatory for LRVL. However, although LRVL has been reported to be an effective, safe and easy method to control portacaval shunts and increase hepatopetal flow in some studies, indications and safety are still not clear. In this review, we summarize existing studies on LRVL during liver transplantation.     

Liver Transplantation in Patients With Complete Portal Vein Thrombosis: Renoportal or Varicoportal Anastomosis Using Cryopreserved Vein Grafts

Background

Despite technical developments in transplantation surgery, complete portal vein thrombosis still remains a challenge for restoration of adequate portal vein inflow. Renoportal or varicoportal anastomosis provides an effective alternative solution for patients with complete portal vein thrombosis. This study describes our experience with renoportal and varicoportal anastomosis during liver transplantation.

Triple-phase computed tomography and intraoperative flow measurements improve the management of portosystemic shunts during liver transplantation.

Ligation of portosystemic shunts in patients with cirrhosis undergoing liver transplantation has been recommended to avoid insufficient portal vein (PV) flow. Shunts are not always recognized pretransplantation because intraoperative PV flow assessment is not routinely attempted. As a result of a posttransplantation PV thrombosis in a recipient with a large portosystemic shunt and a PV flow <1 L/minute, we employed triple-phase computed tomography with vascular reconstruction and intraoperative graft flow measurement to determine the need for inflow modification in our next 16 patients with large portosystemic shunts. Subsequently, 6 patients with large portosystemic shunts and PV flows 相似文献   

Cavoportal hemitransposition in liver transplantation

Over the last decade a large number of patients with portal vein thrombosis have undergone successful liver transplantation. In most of these patients, simple modifications in vascular reconstruction techniques are adequate. However, anastomosis of the donor portal vein may not be possible in the presence of extensive portal and superior mesenteric venous thrombosis and in the absence of any other large tributary of the portal venous system. Cavoportal hemitransposition has been described as a salvage technique under these circumstances. We report a 43-year-old patient who underwent such a procedure and remains well 1 year later. We review the literature and discuss the implications of cavoportal hemitransposition.     

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.     

Renoportal Anastomosis as a Rescue Technique in Postoperative Portal Thrombosis in Liver Transplantation

Renoportal anastomosis has been used as the primary portal revascularization technique in grade 4 portal thrombosis, but never after posttransplant portal thrombosis. A cirrhotic patient with hepatocellular carcinoma and partial portal thrombosis of two-thirds of the lumen was transplanted. The thrombus was removed and good portal flow obtained upon reperfusion (2.8 L/min). On the ninth postoperative day Doppler ultrasound revealed complete portal thrombosis extending from the splenomesenteric confluence. At emergency reoperation, we removed the newly formed thrombus. Portal vein branches were flushed with heparin and urokinase. After reconstruction of the anastomosis, we achieved a flow of 1.1 L/min. Rethrombosis occurred again on day 13. At reoperation, thrombus was removed again. However, this time portal flow was not recovered, due to hepatofugal flow associated with both the presence of collaterals and pancreatic edema. A left renoportal anastomosis was performed using an interposed iliac vein graft. A catheter was placed into the portal vein through a recanalization of the umbilical vein of the graft. After urokinase perfusion, portal inflow was 1.7 L/min. The postoperative course was satisfactory, with progressive normalization of liver tests and no further thrombosis. Persistent ascites improved with treatment. Angiography on day 41 showed good portal flow from the renal vein, with uniform distribution within the liver. A renoportal anastomosis can be useful for recovery of liver failure after posttransplant portal thrombosis, in the absence of portal flow.     

Portosystemic shunt for the treatment of portal vein thrombosis following orthotopic liver transplantation

Abstract The efficacy of the portosystemic shunt operation for the treatment of portal vein thrombosis following orthotopic liver transplantation was demonstrated. From 1 July 1988 to 31 December 1991 42 portosystemic shunt operations were performed at our centre. In six of these cases portal vein thrombosis after orthotopic liver transplantation (OLT) was the indication for the procedure. All the patients retained adequate liver function but they demonstrated manifestations of significant portal hypertension, mainly variceal rebleeding. Two of the patients were children. Three patients underwent distal splenorenal shunt (DSRS), one mesocaval and one side-to-ide splenorenal shunt and the last one side-to-ide splenorenal shunt which was converted to DSRS 2 weeks later. All these patients were doing well after 30 months mean follow-up time without rebleeding or other signs of portal hypertension and none had so far required retransplantation.     

Use of Pericholedochal Plexus for Portal Flow Reconstruction in Diffuse Portal Vein Thrombosis: Case Report

Portal vein thrombosis (PVT) remains a challenging issue for liver transplantation surgeons. Most patients who have PVT undergo eversion thrombectomy. When thrombectomy is not successful due to diffuse PVT, other modalities are adapted, such as the use of a venous jump graft or portal tributaries. Here, we report our successful experience with reconstruction of portal flow using collateral plexus for a patient with grade 4 PVT. Thrombectomy did not restore portal flow. A pericholedochal plexus was found on the lateral wall of common bile duct. Direct end-to-end anastomosis was performed between the donor's portal vein and patient's choledochal plexus. Postoperative color Doppler ultrasound revealed normal portal flow.     

A Single-Center Experience in Portal Flow Augmentation in Liver Transplantation With Prior Large Spontaneous Splenorenal Shunt

Large portosystemic shunts may cause portal steal syndrome in liver transplantation (LT). Because of the possible devastating consequences of the syndrome, the authors recommend perioperative management of these large shunts. Fourteen adult recipients who underwent portal flow augmentation, including left renal vein ligation (LRVL), renoportal anastomosis (RPA), shunt ligation (SL), and splenic vein ligation (SVL) for large spontaneous splenorenal shunt (SSRS), are included in this study, and the results were analyzed. A total of 13 patients had a large SSRS, and in 1 patient, the large shunt was placed between the superior mesenteric vein and the right renal vein. LDLT was performed in 13 patients. LRVL (n = 5), SVL (n = 6), RPA (n = 2), SL (n = 1) were performed to the patients as graft inflow augmentation. The graft-recipient weight ratios (GRWR) were less than 0.8% in 5 patients (35.7%): 2 had LRVL, and 3 had SVL. Small-for-size syndrome (SFSS) occurred only in these 2 patients with LRVL (GRWR ≤0.8%) and, splenic artery ligation was performed for graft inflow modulation. No mortality or serious complications were reported during follow-up. We consider that in patients with large SSRS and small-for-size grafts, SVL can be performed safely and with satisfactory outcomes.     

Hepatic venous outflow reconstruction in adult living donor liver transplants without portal hypertension

Graft congestion is one of the causes of poor graft function in segmental liver transplantation. Three factors are implicated in segmental graft congestion: graft size, hepatic venous outflow and portal inflow. The graft size must be matched to the body weight, which is conventionally done by using graft to body weight ratio. Hepatic blood outflow must be optimized by hepatic vein reconstruction, which can be complicated. High portal blood flow has been shown to be detrimental to small-for-size grafts. These factors are strictly connected to each other. They can all contribute to graft congestion and poor function, while one factor can compensate for the others and decrease congestion. Ideally, all the accessory veins should be reconstructed, if possible, to maximize the outflow. In the absence of portal hypertension and with an adequate sized graft, complex venous reconstruction may not be necessary. We present a case report of an adult living donor liver transplant with the favorable conditions of normal portal pressure and a large sized graft, but complicated by the presence of several accessory hepatic veins. A simple hepatic vein anastomosis was sufficient for adequate outflow and prompt graft function.     

Liver transplantation complicated by misplaced TIPS in the portal vein.

OBJECTIVE: The purpose of this study was to determine the incidence and complications related to transjugular intrahepatic portosystemic shunt (TIPS) stents found in the portal vein at the time of an orthotopic liver transplantation. BACKGROUND: Transjugular intrahepatic portosystemic shunts are frequently used in patients with end-stage liver disease as a bridge to liver transplantation. The incidence of finding the metal stent outside of the liver parenchyma at the time of transplantation is reported as high as 30%. Most cases that have been detailed involve stents misplaced in the vena cava with various outcomes. Almost no data are available regarding stents misplaced into the portal vein. METHODS AND RESULTS: We report our experience with four patients with whom a TIPS stent was found misplaced in the portal vein at the time of liver transplantation, including one patient with a stent extending into the superior mesenteric vein. This patient required extensive venous reconstruction using a retropancreatic "pant" donor-iliac vein graft. The three other patients were transplanted without the need for extensive venous reconstruction. There was no significant difference in operative times for this group of patients, but there was a significant increase in the requirement for blood transfusion. In a follow-up period ranging from 6 months to 2 years, all patients remained alive and had normal portal venous flow and functioning allografts. Most misplaced stents were placed in patients with small cirrhotic livers and by radiologists with minimal experience with the procedure. CONCLUSIONS: Misplaced TIPS in the portal vein before liver transplantation is a more frequent complication than previously reported; however, it does not represent major technical difficulty if a clamp can be placed proximally on the portal vein. In the case of a stent extending below the spleno-mesenteric confluence, interposition grafts such as a donor-iliac vein graft are necessary for venous reconstruction. The experience of the radiologist is critical to prevent this complication.     

New Surgical Approach to Large Splenorenal Shunt in Living Donor Liver Transplantation: Diversion of SMV and SPV Blood Flow

Introduction

The management of a large splenorenal shunt is important because it affects recipient outcome, particularly in living donor liver transplantation.

Methods

To manage large splenorenal shunts in living donor liver transplantation, we diverted superior mesenteric vein and splenic portal vein blood flow by ligation at the root of the splenic portal vein.

Result

This procedure was applied for five patients in whom superior mesenteric vein blood flow had been completely stolen by a splenorenal shunt preoperatively. Postoperative course was excellent in all cases.

Conclusion

This technique completely prevents morbidity related to large splenorenal shunts after living donor liver transplantation.     

Intra-operative management of low portal vein flow in pediatric living donor liver transplantation

For pediatric living donor liver transplantation, portal vein complications cause significant morbidity and graft failure. Routine intra-operative Doppler ultrasound is performed after graft reperfusion to evaluate the flow of portal vein. This retrospective study reviewed 65 children who had undergone living donor liver transplantation. Seven patients were detected with suboptimal portal vein flow velocity following vascular reconstruction and abdominal closure. They underwent immediate on-table interventions to improve the portal vein flow. Both surgical and endovascular modalities were employed, namely, graft re-positioning, collateral shunt ligation, thrombectomy, revision of anastomosis, inferior mesenteric vein cannulation, and endovascular stenting. The ultrasonographic follow-up assessment for all seven patients demonstrated patent portal vein and satisfactory flow. We reviewed our experience on the different modalities and proposed an approach for our future intra-operative management to improve portal vein flow at the time of liver transplantation.     

Noncirrhotic portal vein thrombosis. Physiology before and after shunts.

Controversy exists concerning the proper therapy for bleeding gastroesophageal varices secondary to noncirrhotic portal vein thrombosis. Disparity of opinion exists regarding the significance of hepatic portal blood flow and the consequences of total portal-systemic shunts in this condition. One patient is presented who developed severe, crippling encephalopathy 20 years after a central splenorenal shunt. This was associated with loss of portal flow to the liver and marked nitrogen intolerance. Closure of the shunt resulted in restoration of hepatic portal flow via collateral veins (HPI 0.36), clearance of encephalopathy and return to near normal protein tolerance. An additional patient was studied with hyperammonemia and early suggestive signs of encephalopathy eight years following a mesocaval shunt. Four patients were evaluated before and after selective distal splenorenal shunts. All had "cavernous transformation" of the portal vein with angiographic evidence of portal flow to the liver. Postoperative angiograms revealed continued hepatic portal perfusion and a patent shunt in each patient. Radionuclide imaging postoperatively gave an estimated portal fraction of total hepatic blood flow (HPI) of .39 and .60 in two of the four patients. We conclude that 1) there is significant hepatic portal perfusion in noncirrhotic portal vein thrombosis (cavernous transformation), 2) loss of this hepatic portal flow following total shunts can lead to severe encephalopathy, 3) the selective distal splenorenal shunt maintains hepatic portal perfusion and is the procedure of choice when there is a patent splenic vein and surgical intervention is indicated.     

Portal vein reconstruction in pediatric liver transplantation from living donors.

OBJECTIVE: The authors analyze the surgical pattern and the underlying rationale for the use of different types of portal vein reconstruction in 110 pediatric patients who underwent partial liver transplantation from living parental donors. SUMMARY BACKGROUND DATA: In partial liver transplantation, standard end-to-end portal vein anastomosis is often difficult because of either size mismatch between the graft and the recipient portal vein or impaired vein quality of the recipient. Alternative surgical anastomosis techniques are necessary. METHODS: In 110 patients age 3 months to 17 years, four different types of portal vein reconstruction were performed. The portal vein of the liver graft was anastomosed end to end (type I); to the branch patch of the left and right portal vein of the recipient (type II); to the confluence of the recipient superior mesenteric vein and the splenic vein (type III); and to a vein graft interposed between the confluence and the liver graft (type IV). Reconstruction patterns were evaluated by their frequency of use among different age groups of recipients, postoperative portal vein blood flow, and postoperative complication rate. RESULTS: The portal vein of the liver graft was anastomosed by reconstruction type I in 32%, II in 24%, III in 14%, and IV 29% of the cases. In children <1 year of age, type I could be performed in only 17% of the cases, whereas 37% received type IV reconstruction. Postoperative Doppler ultrasound (mL/min/100 g liver) showed significantly (p < 0.05) lower portal blood flow after type II (76.6 +/- 8.4) versus type I (110 +/- 14.3), type III (88 +/- 18), and type IV (105 +/- 19.5). Portal vein thrombosis occurred in two cases after type II and in one case after type IV anastomosis. Portal stenosis was encountered in one case after type I reconstruction. Pathologic changes of the recipient native portal vein were found in 27 of 35 investigated cases. CONCLUSION: In living related partial liver transplantation, portal vein anastomosis to the confluence with or without the use of vein grafts is the optimal alternative to end-to-end reconstruction, especially in small children.     

成人间活体肝移植后小肝综合征的预防：附6例报告

目的：探讨预防成人间活体肝移植术后小肝综合征（SFSS)的方法。 方法：回顾性分析6例成人间活体肝移植(LDLT)的临床资料,包括受体术前血细胞计数、脾脏厚度、门静脉直径、移植物重量与受体体重比（GRWR）、移植物体积与受体标准肝体积比（GV/SLV）及肝静脉重建等,探讨合适体积移植物、良好肝静脉回流、及正常门静脉灌注对SFSS的预防作用。 结果：受体术前均无严重门静脉高压,均没有采用降门静脉压力与血流的措施,6例肝移植物GV/SLV均大于40%,除1例GRWR为0.74%外,余均大于0.8%。6例受体肝静脉重建均良好,重建后肝脏无淤血改变。术后无SFSS发生。 结论：LDLT通过选择合适体积移植物,重建良好的肝静脉回流,控制门静脉压力,防止门静脉过度灌注等有助于预防SFSS的发生。