A rare case of complex vascular reconstruction in liver transplantation.

Abnormalities of recipient or donor vascular structures are associated with reconstructive difficulties in liver transplantation. A patient with thrombosis of the right hepatic vein and associated stricture of the inferior vena cava (IVC), portal vein thrombosis and multiple aberrant arteries underwent orthotopic liver transplantation. The donor's suprahepatic IVC was anastomosed to the recipient's intrathoracic IVC. The portal vein flow was restored by venous graft interposition, while the arterial flow was ensured by interposing an iliac arterial graft anastomosed to the infrarenal aorta. In conclusion, graft function remains excellent more than 5 years postoperatively.     

大鼠胰十二指肠肾脏联合移植模型的实验研究

目的：为了进行胰肾联合移植基础研究，建立一种简易可靠的大鼠胰十二指肠肾脏联合移植（SPKT）模型，方法：雄性SD大鼠作同品系异体移植的供受体，受体尾静脉注射链脲霉素（STZ）50mg/kg，建立大鼠糖尿病模型，在保存液中，移植物门静脉与肾下下腔静脉作袖套式吻合；移植物肾上腹主动脉，肾上下腔静脉分别与受体肾下腹主动脉，肾下下腔静脉显微缝合吻合，移植物十二指肠与受体十二指肠端侧吻合，移植物带输尿管的膀胱片与受体膀胱吻合。结果：血管吻合时间及受体手术时间短，手术成功率为88％，移植胰腺及肾脏功能良好。结论：此模型是一种简易可靠的大鼠胰十二指肠肾脏联合移植模型。     

Rat liver transplantation for total vascular reconstruction, using a suture method

We developed a novel protocol for rat orthotopic liver transplantation (OLT), using a suture method to establish hepatic artery flow. After determining that early inferior vena cava (IVC) unclamping maintained better circulation compared with the portal vein (PV) using porto-systemic shunted recipients, we developed a rat OLT model with total vascular reconstruction using a suture method. After connecting the suprahepatic IVC, the infrahepatic IVC was anastomosed, using a running suture method. IVC circulation was established immediately. The PV was anastomosed without intestinal congestion, using porto-systemic shunted recipients. The aortic conduit, including the donor celiac and hepatic artery, was anastomosed to the recipient abdominal aorta end-to-side. Eight of 11 OLT cases (72.7%) survived indefinitely. Biliary connection was achieved using a one-stent method. Three cases died 3-5 days postoperatively. Hepatic angiography showed good patency. The graft liver was histologically normal in long-surviving rats.     

小鼠移植肾再次移植动物模型的建立

目的探讨小鼠移植肾再次移植动物模型建立方法。方法将首次移植供体小鼠左侧供肾肾静脉(RV)同首次移植受体小鼠肾下下腔静脉(IVC)端侧连续吻合,首次移植供体小鼠左侧供肾肾动脉(RA)连带小段首次移植供体小鼠腹主动脉(AO)同首次移植受体小鼠AO端侧间断吻合,首次移植供体小鼠左侧供肾输尿管拖入并固定在首次移植受体小鼠膀胱顶后壁完成小鼠首次肾移植术。首次移植术后2~4周,将首次移植受体小鼠体内移植肾脏RV连带部分首次移植受体IVC同移植肾再次移植受体小鼠IVC端侧连续吻合,移植肾脏RA连带小段首次移植供体和受体小鼠AO同移植肾脏再次移植受体小鼠AO端侧间断吻合,将再次移植肾输尿管拖入并固定在再次移植受体小鼠膀胱顶后壁完成小鼠移植肾再次肾移植术。首次移植和移植肾再次移植术中均切除受体双侧自体肾脏。记录手术时间,随访移植肾再次移植受体存活,监测再次移植肾功能和病理。结果移植肾再次移植供体手术时间为(50±10)min,受体手术时间为(55±5)min。共完成8例小鼠移植肾再次移植术。2例同系,6例非同系。第1例尝试性非同系移植肾再次移植受体存活11 d。后续5例非同系移植肾再次移植受体中1例存活21 d,其余4例均存活到术后70 d获取标本。2例同系移植肾再次移植受体均存活到术后30 d获取标本。8例移植肾再次移植受体在获取标本时或非预期死亡前血清肌酐均<0.2 mg/dl。苏木精-伊红(HE)染色提示同系移植肾再次移植术后30 d移植肾未见病理性改变。结论本文描述了建立小鼠移植肾再次移植动物模型的方法,为开展移植免疫相关研究提供了新手段。     

A new venous conduit utilizing the recipient portal vein branches for segment V in adult partial liver transplantation

Right anterior-medial lobe congestion due to temporary clamping of segment V and/or VIII is common in the operative theater during adult donor right lobe liver transplantation, the most common procedure in our institute. We have used an autogenous saphenous vein conduit to recipient portal vein tributaries in 15 cases, as a "Y-to-I venoplasty" since January 2004. The recipient portal vein is transected 5 mm proximal to its bifurcation and extended to both sides with partial hepatic dissection. The "Y-to-I venoplasty" is made by suture closure of the portal vein transversely to form a tube. The average length is 7.5 cm with a 1.3 cm width. One end of "Y-to-I venoplasty" conduit is anastomosed to the donor segment V branch on the back table. And the other end is anastomosed directly to the IVC via a new window or the middle hepatic vein stump in recipient. The phase distension of the conduit with respiration is noted in the operative field. A 6/15 (40%) patency rate, was observed by CT angiography at the second postoperative week. All-patient conduits showed good flow on serial examinations at the 60th postoperative day. This new venous graft, made of recipient portal vein is a good conduit for segment V decongestion in adult right lobe partial liver transplantation.     

A Novel Technique for Auxiliary Partial Liver Transplantation With Reno-Portal Anastomosis and Avoidance of the Hepatoduodenal Ligament

Auxiliary liver transplantation (ALT) is a treatment for acute liver failure when regeneration of the native liver is possible or for metabolic disorders. In selected cases ALT and orthotopic liver transplantation (OLT) have similar survival when ALT is performed in the orthotopic position (auxiliary partial orthotopic liver transplantation, APOLT). Drawback of ALT with portal vein to portal vein anastomosis is the frequent occurrence of thrombosis, compromising both graft and native liver, and the necessity of a significant resection. To avoid division of portal flow we performed ALT with an end-to-end anastomosis between the graft portal vein and the left renal vein of the recipient (reno-portal ALT, REPALT). The hepatic artery was anastomosed to the aorta using an iliac arterial graft conduit. The bile duct was anastomosed to the stomach. In the two cases presented here excellent immediate graft function occurred with rapid regeneration of the graft and without early vascular complications.     

Combined pancreatic and kidney transplantation: en bloc retrieval and transplantation - a new surgical technique

Abstract We designed and performed on two patients a new surgical procedure of en bloc kidney and pancreatic transplantation. The liver, pancreas and kidneys were removed en bloc in the donor. On the bench, the liver and the left kidney were separated from the bloc, leaving the pancreas and the right kidney for combined kidney and pancreatic transplantation, The portal vein was divided near to the emergence of the splenic vein. The coeliac axis was taken with an aortic patch. The left renal vein was cut at its entrance to the inferior vena cava (IVC) and the left renal artery was taken with an aortic patch. Reconstruction of the pancreatic vessels was performed with a double anastomosis: the portal vein was anastomosed to the hole in the IVC resulting from the section of the left renal vein and the splenic artery was anastomosed to the hole in the aorta resulting from the section of the left renal artery. The proximal ends of the aorta and IVC were closed with running sutures. In the recipient, the iliac vessels on the right side were dissected. Anastomosis of the distal part of the aorta and the IVC was performed with the right iliac vessels. Duodenocystostomy and reimplantation of the ureter were done according to the usual techniques. This new surgical technique allowed an easy vascular reconstruction of the pancreatic vessels. In the recipient, only one side was used for renal and pancreatic transplantation. Moreover, the length of the transplant procedure was significantly reduced.     

Review of various techniques of small bowel transplantation in pigs

Because of anatomical and physiological similarities to humans, porcine small bowel transplantation (SBTx) can be used as an appropriate experimental model in the field of surgical research. Various approaches to SBTx have been described in literature. The aim of this work is to present a review of different surgical techniques of SBTx which have been developed using the porcine model. Our analysis of Medline-cited studies dealing with different techniques of SBTx in porcine models was particularly focused on surgical aspects. With regard to graft procurement and enterectomy, the reported techniques vary widely. Arterial reconstruction is mainly conducted by performing the anastomosis between the superior mesenteric artery (SMA) of the donor and SMA or infrarenal aorta of the recipient. Alternatively, an aortic segment of the donor can be anastomosed to the infrarenal aorta of the recipient. Venous anastomosis is frequently performed between the superior mesenteric vein (SMV) of the donor and SMV or the inferior vena cava (IVC) of the recipient. Some studies also report venous anastomosis between the portal vein of the donor and the recipient. Bowel continuity is then restored by end-to-end or end-to-side anastomosis. Remarkable results were generated thanks to improved techniques which include proximal side-to-side ileo-ileal anastomosis with double-barrel ileostomy, or so-called "Paul-Mikulicz-Ileostomy". Most frequently used were jejunostomy and the "Bishop-Koop-Ileostomy"--where the proximal part of the bowel is anastomosed end-to-side to the distal part, which is then exteriorized as an ostomy. Based on the techniques presented in this review, one must select the most suitable surgical technique of porcine SBTx among those various models.     

Living domino liver transplantation in an adult with congenital absence of portal vein.

Congenital absence of the portal vein (CAPV) is a rare malformation of the splanchnic venous system. Although CAPV is usually detected in the pediatric age group, our patient was a 35-year-old woman. She had been diagnosed with CAPV in 1996 when she was 27 years old. In 1998, she was placed on hemodialysis due to chronic renal failure. After several episodes of encephalopathy in 2002, liver transplantation (LT) was recommended to her and her family. Since there was no suitable living donor candidate, she was put on the waiting list for a deceased donor liver transplant in Japan. In 2004, her ammonia level increased to around 300 microg/dl, and she went into a coma lasting for three days. After recovering from this event, she underwent a living domino transplantation using a whole liver donated by a familial amyloid polyneuropathy (FAP) patient. Her portal vein, which had drained directly into the inferior vena cava (IVC), was transected together with a cuff of the IVC wall and anastomosed to the graft liver portal vein in an end-to-end fashion. In conclusion, liver transplantation proved to be a safe and effective way to save this patient and improve her quality of life.     

用袖套式血管吻合法建立大鼠肝、肠联合移植模型

目的 建立肝、肠联合移植手术模型。方法 用Ｗｉｓｔａｒ大鼠行同种异体肝、肠联合移植。先行肝移植,再行小肠移植。肝脏为原位移植,供肠异位移植于左肾处（切除左肾）。门静脉、肝下下腔静脉和肠系膜上静脉采用袖套式吻合法分别与受者的门静脉、肝下下腔静脉和左肾静脉吻合,回肠末端在左下腹造瘘。结果 手术成功率为６２．５％,动物平均存活时间１１．２ｄ。组织学检查发现移植肝和小肠发生排斥反应。结论 用袖套式血管吻合     

Portal Vein Stent Placement in Anastomotic Stenosis After Deceased Donor Liver Transplantation: A Case Report

Vascular complications (VCs) after liver transplantation (LT) frequently result in graft and patient loss. The smaller vessels and the insufficient length for reconstruction in living donor LT and pediatric transplantation predispose patients to a higher incidence of VCs. Herein we present a case of portal vein stenosis (PVS) in an adult deceased donor LT recipient with portal vein thrombosis requiring extended thrombectomy at the time of LT. He presented with ascites 4 months after LT, was diagnosed with PVS, and was successfully treated with percutaneous transhepatic venoplasty and placement of a portal stent. This case highlights the importance of Doppler ultrasound as a screening modality for detection of VCs after LT and the pivotal role of endovascular repair as a first-line treatment for PVS.     

Hepatic venous outflow reconstruction in right live donor liver transplantation.

The increasing experience with live donor liver transplantation has allowed for the identification of potential morbidities associated with technical considerations. Technical graft failure can be associated with both inflow and outflow vascular compromise. Although the latter has not always been given the relevance of the former, evidence pointing to its pivotal role continues to mount. We believe that impaired venous outflow was a cause of previously unexplained graft failures during our initial experience. Based on this observation, we developed a technique to prevent the "choking" of the graft at the outflow anastomosis with the inferior vena cava (IVC). The enhanced outflow via a cloaca maximum is achieved by reconstructing the graft vessels with preserved veins or arteries (usually iliac vessels are used) from a blood-group-identical or blood-group-compatible deceased organ donor. Alternatively, hepatic vein or portal vein obtained from the resected native liver can be used. The reconstructed common outflow is anastomosed to a triangular opening of the IVC. Such enhanced outflow provides optimal venous drainage, especially during the early phase of growth of the graft.     

Simplified technique of orthotopic liver transplantation in pigs

BACKGROUND: Pig models have become common in transplantation immunological research. However, in pigs, clamping of the venous splanchnic system during orthotopic liver transplantation (OLT) is responsible for high morbidity and mortality rates; therefore, the use of venovenous bypass (VVB) is advocated. Because venous bypass can also cause specific complications, a simplified method for OLT in pigs has been developed and evaluated in terms of morbidity and mortality. METHODS: Twenty-three OLTs were performed between pairs of inbred miniature swine. Donor and recipient pairs (weighing 20-35 kg) were selected at 3-6 months of age. In the donor, the portal vein, infrahepatic vena cava, and suprahepatic vena cava were dissected, whereas the hepatic artery was preserved in continuity with the coeliac trunk and the abdominal aorta up to the iliac bifurcation. In situ cold perfusion was then performed. The recipient was prepared simultaneously by another surgical team. After total hepatectomy and complete portal and caval clamping, the suprahepatic vena cava and portal vein were sutured; VVB was not used. After completion of both venous sutures, the liver graft was reperfused. The infrahepatic vena cava was then anastomosed and unclamped. The donor aorta conduit was implanted end-to-side to the recipient infrarenal aorta, and the biliary reconstruction consisted of a cholecystojejunostomy with a Roux-Y loop. RESULTS: Twenty of 23 (87%) animals survived more than 1 week (7-483 days). The mean anhepatic time was 29.6+/-4.12 min. Although severe hypotension was noted during the anhepatic phase, the hemodynamic status rapidly recovered and stabilized after graft reperfusion. CONCLUSION: Simplified technique without VVB is appropriate for successfully achieving OLT in pigs.     

肝细胞胸腺内注入对大鼠异位小肠移植物的影响

目的 研究大志胸腺内注入异体抗原对异体小肠移植的影响。方法 在未用任何免疫抑制剂的情况下,将ＤＡ大鼠的肝细胞注入ＰＶＧ大鼠的胸腺内,１周后行周种异位小肠移植。结果 ３周内胸腺中注入的同种异体肝细胞存活;移植小肠遭强烈排斥,受者死亡,但胸腺内注入同一供者的肝细胞仍存活。结论 胸腺内注入同种异体肝细胞不能诱导受者对同一供者小肠移植物的免疫耐受。     

经升主动脉灌注的无心跳供体大鼠原位肝移植模型的建立

目的 探讨建立一个能灌注更彻底、更易操作、热缺血时间容易控制的原位肝移植动物模型。方法 在Kamada两袖套法的基础上进行改良，供体经升主动脉进行冷灌注，肝上下腔静脉用缝合法吻合，门静脉和肝下下腔静脉用袖套法吻合，胆总管采用胆管内支架端端吻合的方法。建立无心跳供体的大鼠原位肝移植模型。结果 40例移植后1d大鼠存活率为95．0％(38／40)，1周存活率为85．5％(35／40)。结论 经升主动脉灌注的供肝灌注更彻底、均匀，更易操作，热缺血时间控制更精准，行肝移植后1周存活率较文献报道高。     

Surgical techniques for vascular reconstruction of the portal vein and hepatic artery in living-donor liver transplantation]

To decide how to reconstruct the portal vein and hepatic artery for liver transplantation, anatomical variation, diameter, length, and injury to vessels during surgery, and the quality of recipient vessels should be considered. Hence, it is of key importance for donor and recipient surgeries to prepare adequate vessels for reconstruction. For reconstruction of the portal vein, anastomosis with as large a diameter as possible is required to obtain good portal flow. In cases with sclerosing stenosis and old thrombus, technical innovations such as branch-patch, a conduit using a vein graft, and venoplasty using a venous patch are necessary. For reconstruction of the hepatic artery, selecting a satisfactory recipient artery, overcoming size mismatch, and gentle handling of a recipient artery with pathological changes are important. Arteries smaller than 3 mm are anastomosed with a surgical microscope using the united suture technique. The fishmouth technique or funnelization technique can be used for anastomoses with a significant size mismatch, and an autoarterial graft is used when arteries do not reach each other.     

亲属活体单段供肝移植治疗极低体重婴儿胆道闭锁一例

目的 总结亲属活体单段供肝移植治疗极低体重婴儿胆道闭锁的临床经验.方法 受者为出生仅145 d的男婴,身高66 crn,体量3.08 kg,被确诊为胆道闭锁伴肝硬化.供者为患儿母亲,年龄36岁,身高145 cm,体重47 kg.采用改良背驮式原位肝移植术,切取供者Ⅱ段肝组织作为供肝,移植肝体积与受者标准肝体积比值为92.5%,GRWR为5.19%,供肝动脉与受者肝右动脉用供者左侧股外侧浅隐静脉搭桥行端端吻合,受者三支肝静脉经整合后与供肝静脉行端端吻合,供肝胆管与受者空肠行Roux-en-Y吻合.术后监测供、受者生命体征、肝肾功能及出血和凝血状况等,常规抗感染治疗.受者术后采用环孢素A、吗替麦考酚酯及甲泼尼龙的方案预防排斥反应.结果 供肝切取手术历时370 min,术中供者出血150 ml均回输,切取供肝重量为160 g.肝移植手术历时451min,术中受者失血230 ml,输注全血200 ml和红细胞悬液50 m1,无肝期时间为71 min,供肝冷缺血时间为132 min.供者恢复顺利,术后8 d拆线出院.受者术后5 d肝功能基本恢复正常,术后7 d各项化验指标均正常.但术后7和15 d时,受者分别发生肠道吻合口漏各1次,经修补后痊愈.受者于术后35 d出院,出院时体重增加0.3 kg,各方面与同龄婴儿相当.结论 亲属活体单段供肝移植是治疗极低体重患儿终未期肝病的一种可供选择的治疗方法,经充分的术前评估、精细的手术操作及良好的围手术期管理后,手术能取得良好效果.     

Simultaneous pancreaticoduodenal-kidney transplantation in rats.

AIMS: To establish a stable and simple simultaneous pancreaticoduodenal-kidney transplantation model in rats. METHODS: Pancreaticoduodenal-kidney (left) and 1 cm of the inferior vena cava (IVC) with 0.5 cm left and right iliac communis vein were harvested from donors. We performed 'cuff' anastomoses between (1) portal vein and right iliac communis vein and (2) left kidney vein and left iliac communis vein, converging donor portal vein and left kidney vein into IVC together. Next, we performed an anastomosis of donor arterial segment and recipient abdominal aorta and a 'cuff' anastomosis between donor IVC and recipient left kidney vein. RESULTS: Of 40 transplanted rats in which diabetes was induced, 33 survived over 7 days, and 31 rats have survived over 4 months. 30 rats' nonfasting plasma glucose levels were euglycemic. CONCLUSIONS: We performed three 'cuff' anastomoses to simplify the surgical procedure and to shorten the ischemic period of the graft. The recipient vein system has an integrated membrane to avoid thrombi in venous anastomosis sites, enhancing the transplantation success rate.     

Combined pancreaticoduodenal-kidney transplantation in rats

The objective of this work was to establish a stable and simple simultaneous pancreaticoduodenal-kidney transplantation model in rats. The methods involved harvesting a pancreaticoduodenal-kidney (left) (PDK) and 1-cm inferior vena cava (IVC) with a 0.5-cm left and right iliac communis vein from donors and to "cuff" anastomose between portal vein and right iliac communis vein, left kidney vein, and left iliac communis vein, converging donor portal vein and left kidney vein into IVC together. Next, we performed an anastomosis of the donor arterial segment and recipient abdominal aorta and a "cuff" anastomosis between donor IVC and recipient left kidney vein. Of 67 transplanted rats in which diabetes was induced, 57 survived >7 days, 55 survived 1 month, 54 rats have survived >4 months. In 51 rats, nonfasting plasma glucose levels were euglycemic. We performed three "cuff" anastomoses to simplify the surgical procedure and to shorten the ischemia time of the graft; the recipient vein system has an integrated endovenous membrane to avoid venous thrombi in venous anastomosis sites.     

Technique for retransplanting heterotopic heart grafts in mice

Removal of a transplanted organ from its original recipient and retransplanting it into a new host is an important method to study the role of the graft in the rejection process. Here we describe a novel technique of heart retransplantation in the mouse. In this technique, a primarily vascularized heart graft is anastomosed to the abdominal aorta and inferior vena cava of a syngeneic or immunodeficient allogeneic mouse, using standard techniques. Either 10 or 70 days later, the same graft is retransplanted into the abdomen of a second mouse by end-to-side anastomosis of the donor (first recipient) aortic and inferior vena cava's cuffs to the second recipient's abdominal aorta and inferior vena cava, respectively. A greater than 90% success rate was achieved by using this microsurgical technique. This method should be useful for studying intragraft factors, such as ischemia-reperfusion injury and donor antigen-presenting cells, on the outcomes of transplantations.