Modified liver hanging maneuver during orthotopic liver transplantation with inferior vena cava preservation: results after 120 consecutive applications

The outflow venovenous anastomosis represent a crucial aspect during orthotopic liver transplantation (OLT) with inferior vena cava (IVC) preservation. The modified Belghiti liver hanging maneuver applied to the last phase of hepatectomy, lifting the liver, provides a better exposure of the suprahepatic region and allows easier orthogonal clamping of the three suprahepatic veins with a minimal portion of IVC occlusion. The outflow anastomosis constructed with a common cloacae of the three native suprahepatic veins is associated with a lower incidence of graft related venous outflow complications. The procedure planned in 120 consecutive OLT was achieved in 118 (99%). The outflow anastomosis was constructed on the common cloaca of the three hepatic veins in 111/120 cases (92.5%). No major complications were observed (bleeding during tunnel creation, graft outflow dysfunction, etc) except in one patient with acute Budd-Chiari, who successfully underwent retransplantation.     

Isolated right hepatic vein obstruction after piggyback liver transplantation.

The "piggyback" technique for liver transplantation has gained worldwide acceptance. Still, complications such as outflow obstruction have been observed, usually attributable to technical errors such as small-caliber anastomosis of the suprahepatic vena cava, twisting, or kinking. Iatrogenic Budd-Chiari syndrome after piggyback liver transplantation has been reported as a consequence of obstruction involving the entire anastomosis (usually the 3 hepatic veins). Here we describe technical issues, clinical presentation, diagnosis, and treatment of 3 cases in which outflow obstruction affected only the right hepatic vein. In conclusion, all 3 patients developed recurrent ascites requiring angioplasty and/or stent placement across the right hepatic vein to alleviate the symptoms.     

Venous complications after orthotopic liver transplantation

Complications involving the portal vein or the vena cava, are rare after orthotopic liver transplantation. We report on the incidence and treatment of venous complications following 1000 orthotopic liver transplantations in 911 patients. Twenty-six of the adult patients (2.7%) suffered from portal complications after transplantation, whereas complications of the vena cava were observed in only 17 patients (1.8%). Technical problems or recurrence of the underlying disease (e.g. Budd-Chiari syndrome) accounted for the majority of complications of the vena cava, whereas alteration of the vessel wall or splenectomy during transplantation could be identified as important risk factors for portal vein complications. In patients undergoing modification of the standard end-to-end veno-venous anastomosis of the portal vein due to pathological changes of the vessel wall, complications occurred in 8.3%, whereas only 2.4% of patients who received a standard anastomosis of the portal vein experienced complications of the portal vein. Furthermore, splenectomy during transplantation was also associated with an increased incidence of portal vein complications (10.5 vs. 2.2% in patients without splenectomy). Treatment was dependent on the signs and symptoms of the patients, and varied considerably between patients with portal vein complications and patients suffering from complications of the vena cava. Complications of the vena cava led to retransplantation in about one-third of the patients, whereas in patients with occlusion of the portal vein, retransplantation was necessary in only 15%, and more than half of the patients suffering from portal vein complications did not require any treatment at all. Usually, treatment of patients with portal vein complications only became necessary when additional complications such as arterial occlusion or bile duct injuries occurred.     

经腹肝上下腔与肝后下腔静脉人工血管架桥术治疗Budd-Chiari综合征

目的:探讨治疗Budd-chiari综合征有效的手术方式。方法:肝后下腔静脉短节段闭塞型Budd-chiari综合征,16例采用经腹行肝上下腔静脉与肝后下腔静脉人工血管架桥术(改良手术组),相同病理类型18例应用开胸行右心房与肝后下腔静脉人工血管架桥术(传统手术组),进行疗效对比研究。结果:改良手术组16例中,术中1例急性右心衰,15例术中经过顺利。人工血管长度6~8cm,随访6~55个月人工血管内无血栓形成。传统手术组18例中,术中急性心包填塞1例。术后发生胸腔积液3例,肺部感染与急性心包炎各1例。人工血管长度12~14cm。术后随访60个月,有3例分别于术后37、42、58个月出现人工血管内血栓。结论:经腹腔行肝上下腔静脉与肝后下腔静脉人工血管架桥术临床效果优于传统的开胸行下腔静脉右心房人工血管架桥术,该手术是治疗肝后下腔静脉短节段闭塞型Budd-chiari综合征安全有效的手术方式。     

Liver transplantation in a patient with complex anomaly of the inferior vena cava

Background

After the introduction of noninvasive imaging exams, congenital anomalies of the inferior vena cava (IVC) have become more commonly recognized. We report the first successful orthotopic liver transplantation (OLT) performed in an asymptomatic adult with complex IVC anomaly: duplication of the infrarenal IVC, azygos continuation of the IVC, agenesia of the hepatic portion of the IVC and presence of several anomalous veins communicating the common iliac vein and the IVC of one side with the contralateral side.

Methods

This complex anomaly was diagnosed with a venous abdominal angio CT.

Results

At liver transplantation, the short suprahepatic portion of the IVC was identified and clamped. The right, middle, and left hepatic veins were sectioned and joined in a single, wide cuff, using venoplasty. This single orifice was anastomosed to the suprahepatic IVC of the new liver. No venovenous bypass was employed. The patient had an uneventful postoperative course. A post transplantation venous abdominal angio CT showed normal blood flow at the anastomosis of the hepatic veins of the receptor and the IVC of the new liver.

Conclusions

This report is important to alert liver transplant teams of the possibility of complex IVC in asymptomatic adult individuals. Identification of these anatomical anomalies is vital to reduce the risk of serious hemorrhage and other operative complications during OLT.     

Surgical complications accompanying liver transplantation in Estonia

The purpose of this study was to evaluate surgical complications accompanying the introduction of orthotopic liver transplantation (OLT) in Estonia. Between 1999 and 2009, we performed the first 12 liver transplantations. Eight patients were males and four were females of age range 12 to 67 years. Their diagnoses were cholestatic disease (n = 5); tumor (n = 3); hepatitis C virus cirrhosis (n = 2); Budd-Chiari syndrome (n = 1); and cystic fibrosis (n = 1). Technical complications occurred in 7/12 patients. The early vascular complications in two patients were a suprahepatic vena cava lesion occurring at liver extraction, which resulted in uncontrolled suprahepatic bleeding after liver perfusion; the recipient died during transplantation. The other case displayed a right intrahepatic portal venous thrombosis, which was treated successfully with thrombolysis and anticoagulant therapy. Early biliary complications of biliary leaks occurred in three patients: two had undergone duct-to-duct reconstructions, which were treated by endoscopic retrograde cholangiography that successfully managed the anastomotic and recipient cystic duct leaks with a papillotomy and stenting. In one patient with a duct-to-jejunum anastomosis, a bile leak stopped at 3 weeks but he needed surgical therapy 2 years later due to an anastomotic stricture. Severe decubitus occurred in the lumbosacral region of the subjects with operating times of 14 hours. They required necretectomy and plastic surgery. One of them with postoperative intra-abdominal hypertension also displayed wound eventration requiring reoperations. The rate of hepatic (5/12) and extrahepatic (3/12) surgical complications, as well as of 1-year survival (9/12), in our period of implementation of OLT were satisfactory to continue OLT development in Estonia.     

Replacement of the retrohepatic vena cava in segmental liver transplantation

Reduced grafts represent an important technical development in paediatric liver transplantation. The use of a left lateral segment graft has required preservation of the native inferior vena cava to “piggy-back” the graft onto it. We report four children who underwent left lateral segment transplantation with caval replacement using the donor iliac vein because the native retrohepatic inferior vena cava was small, friable or difficult to preserve. There were no caval or hepatic vein complications post-transplant and the donor iliac vein proved to be a satisfactory interpositional graft. The technique offers the advantages of a wider retrohepatic cava avoiding venous outflow or caval obstruction, provides good tissue to suture and is well suited for the triangulation technique of the left hepatic vein. Received: 24 January 1997 Received after revision: 20 June 1997 Accepted: 30 June 1997     

背驮式肝移植静脉回流道重建的改进和血流动力学探讨

目的 探讨合理的背驮式肝移植（PBLT）静脉回流道重建方式。方法 将74例PBLT按不同的静脉回流道重建方式分为5组：肝上下腔静脉－肝静脉端端吻合（A组）、肝上下腔静脉－肝后下腔静脉端侧吻合（B组）、肝后下腔静脉－肝后下腔静脉侧侧吻合（C组）、肝上下腔静脉－右心房端侧吻合（D组）、肝后下腔静脉、肝后下腔静脉全口吻合（E组）。比较各组受者的中心静脉压（CVP）、肝后下腔静脉压（RHIVC）及供者肝上下腔静脉靠近吻合口部压力（GIVC），并观察术中布加氏综合征发生情况。结果 C组无论是CVP、RHIVC、GIVC，还是压力差均较A组与B组为小，D组与E组血流动力学测定与C组相似。说明该种术式的供肝静脉回流通畅度令人满意，其术中布加氏综合征发生率也较低。结论 供肝静脉回流道重建方式改进后，供肝静脉回流更通畅，布加氏综合征等并发症发生机率减小。故推荐使用供肝肝后下腔静脉与受者肝后下腔静脉侧侧吻合术式。     

再次肝移植手术技巧:附24例报告

目的探讨再次肝移植的手术技巧。方法总结近4年多来24例行再次肝移植术患者的临床资料。全部采用改良背驮式原位肝移植术。6例采用体外静脉转流，18例未转流。肝上下腔静脉吻合应用附加腔静脉成形一改良背驮式。门静脉重建均为端端吻合。肝动脉的重建：7例为肝动脉、腹主动脉搭桥术，余均为肝动脉端端吻合术。胆道的重建：6例为胆管、胆管端端吻合术，余均为胆管、空肠吻合术（Roux—en—Y或Warren术式）。对所有患者进行随访。结果住院期间病死率为41．6％（10／24）。死亡原因：脓毒症7例；手术出血性休克2例；脑血管意外1例。痊愈率为58．4％（14／24）。痊愈患者并发症发生率为21．4％（3／14），包括胆道并发症2例，伤口裂开1例。结论再次肝移植与初次肝移植手术时间及出血量无显著差异。针对患者进行个体化处理是手术成功的关键。手术难点在于下腔静脉的显露与游离。肝动脉搭桥及胆肠吻合机率高于初次肝移植。     

Management of Extensive Retrohepatic Vena Cava Defect in Recipients of Living Donor Liver Transplantation

Certain complexities, such as extensive vena caval injury, unexpected dense adhesions between liver and retrohepatic vena cava, and liver tumor abutting retrohepatic vena cava, sometimes warrant resection of vena cava during living-donor liver transplantation. Because the donor graft is devoid of vena cava, reconstruction of the retrohepatic cava is required, which can be done with the use of either a cryopreserved venous graft or an artificial conduit. With only a few published reports, the experience in vena cava reconstruction with the use of expanded polytetrafluoroethylene (ePTFE) during living-donor liver transplantation remains limited. We present our experience of 4 patients who successfully underwent vena caval resection during liver transplantation for various indications, which was subsequently reconstructed with the use of ePTFE grafts. All of these patients except 1 recovered well without any undue complications, such as thrombosis or outflow inadequacies, thus proving this extensive surgical treatment to be a successful and life-saving procedure, though meticulous skills are prerequisite.     

Extensive Inferior Vena Cava Thrombosis in a Liver Transplant Patient: A Case Report

Thrombosis of the inferior vena cava is a clinical condition with very diverse presentations, ranging from asymptomatic patients to others with severe edema in the legs and lower torso. We report the case of a 27-year-old female patient, previously diagnosed with autoimmune hepatitis, with asymptomatic extensive thrombosis of the inferior vena cava. The thrombus extended from the renal veins up to the emergence of the hepatic veins, causing post-sinusoidal portal hypertension (Budd-Chiari syndrome). The patient underwent an orthotopic cadaveric liver transplant with removal of the retrohepatic vena cava and thrombectomy of blood clots from the infrahepatic vena cava. She initially recovered well from surgery, but on the 8 postoperative day she had a significant increase in hepatic injury markers and was diagnosed with rethrombosis of the inferior vena cava and hepatic veins. A surgical thrombectomy was performed, with an intraoperative finding of chronic thrombus in both renal veins, previously undiagnosed. The thrombectomy was successful, but the patient's hepatic function continued to worsen and a second liver transplant was performed. After the second transplant she underwent several imaging exams that showed no signs of rethrombosis. She was kept on postoperative anticoagulation indefinitely, first with intravenous heparin then with rivaroxaban. An extensive investigation failed to identify any causes of thrombophilia associated with this vast thrombosis. She is currently alive and with good graft function 1 year and 4 months after the second transplant.     

Retransplantation of the liver in the rat

A successful technique of liver retransplantation in the rat is described. Heterotopic nonauxiliary liver engraftment of a whole liver using cuffed anastomoses is the primary transplant procedure. The graft is implanted in the right hypochondrium and is revascularized by a portal end-to-end anastomosis. Venous drainage is via an end-to-side anastomosis between the donor infrahepatic vena cava and recipient right renal vein. The graft suprahepatic vena cava is ligated. Biliary drainage is achieved by a double stent anastomosis of the biliary ducts. Total parenchymectomy of the recipient's liver is completed leaving intact the intrahepatic and suprahepatic vena cava. Retransplantation in the orthotopic position can thus be attempted, after removal of the first graft, by cuffed anastomoses between the donor and recipient portal veins, infrahepatic vena cava and a double stent anastomosis of the common bile ducts. Anastomosis between the donor and recipient suprahepatic vena cava is completed with a 7/0 Prolene running suture. In the first group of operations (n = 6), a three week survival rate of 50% after retransplantation was obtained. Using the technical lessons of these preliminary cases, 80% of the second group of operations (n = 5), were successful in the long term. Utilization of this new technique may allow further investigations in different fields of research dealing with liver surgery and transplantation. © 1993 Wiley-Liss Inc.     

Utilization of autologous vein graft for replacement of the inferior vena cava in living-donor liver transplantation for obliterative hepatocavopathy

Obliterative hepatocavopathy (OHC) is a subtype of Budd-Chiari syndrome in which stenosis or obstruction of the retrohepatic inferior vena cava (IVC) is observed. Although IVC replacement is necessary in OHC patients, there are hardly any graft vessels available for IVC reconstruction during living-donor liver transplantation (LDLT). Here, we describe a novel technique of IVC reconstruction using only the autologous blood vessels in an OHC patient during LDLT. In this case, sufficient drainage of the hepatic outflow and reconstruction of the venous return from the lower half of the body were simultaneously required. Therefore, we substituted the retrohepatic IVC with the suprarenal IVC of the recipient, and we reconstructed the IVC continuity by using the autologous internal jugular vein and external iliac vein. The operation was safe, and the postoperative venous drainage from the hepatic tributaries was in good condition. This procedure might be an option for IVC replacement during LDLT.     

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.     

47次猪肝移植手术分析

目的研究猪肝移植各种术式优缺点及技术难点,为临床应用积累经验,提供依据。方法施行47次猪肝移植手术,分为猪原位肝移值(OLT组共27对)和背驮式肝移植(PBOLT组共20对)进行研究,总结手术得失,探讨术中并发症的特点和原因。结果术中常见并发症为出血、凝血功能障碍、低血压、肾功能衰竭、血管吻合口渗漏等。OLT组手术成功率为62．9％,体外转流结束时易发生血压波动,肝上下腔静脉暴露吻合较为困难。PBOLT组手术成功率为60％,在游离肝后下腔静脉过程中易出血。结论猪原位肝移植和背驮式肝移植各自的技术难点不同。而术中术后的主要并发症大致相同,可采取有效方法预防。     

单人操作建立小鼠原位肝移植模型

目的：探讨一种能稳定、高效地建立小鼠原位肝移植模型且能单人操作的手术改良方法。方法：参照“双袖套”法,肝上下腔静脉采用连续缝合,门静脉、肝下下腔静脉采用袖套法,胆管用支架法吻合,完成小鼠原位肝肝移植70例。术后观察24 h,1周和1个月受体存活率,肝功能及肝组织病理变化。并设立假手术组对照。结果：受体术后24 h,1周和1个月存活率分别为95.7%,90.9%和85.1%。术后1周ALT逐渐升高,1个月降至正常水平;术后ALP值逐渐增高;病理显示肝组织结构良好。结论：该方法成活率高,稳定性好,重复性强,是建立小鼠原位肝移植模型的理想方法。     

Modified Technique of Mesh Hepatorrhaphy for Management of Juxtahepatic Venous Injury in a Case of Blunt Liver Trauma: A Case Report

The liver is the most frequently injured organ in cases of blunt abdominal trauma. Injuries to the caudate lobe are rarely isolated and usually associated with retrohepatic caval injury or hepatic vein injury. The management of the associated vascular injuries is usually difficult owing to the short courses of the hepatic veins and the difficulty in obtaining proximal and distal control of the suprarenal and suprahepatic inferior vena cava – hence the frequency of perihepatic packing in the management of caudate lobe and hepatic venous injuries. We present here a rare case of the failure of perihepatic packing to effectively control hemorrhage from blunt injury to the caudate lobe and retrohepatic vena cava. A case of blunt abdominal trauma with injury to the caudate lobe and retrohepatic venous injury was initially managed with perihepatic packing. The patient developed hemorrhage 48 h after pack removal, which was then successfully managed with mesh hepatorrhaphy of the caudate lobe.     

三袖套法大鼠原位肝移植术后近期并发症及死因分析

目的 探讨建立稳定的三袖套法大鼠原位肝移植模型。方法 对行三袖套法肝移植术后近期死亡的２８例大鼠进行解剖,分析其术后并发症及死亡原因。结果 术后并发症主要为：出血,肝上腔静脉狭窄,门静脉血栓,呼吸道梗阻,胃扩张,气胸,肝,膈粘连,胆道梗阻。结论 术后发生的８种并发症中多娄与手术操作有关。     

Transabdominal Intrapericardial Approach in Liver Transplantation for Unresectable Primary Hepatic Functioning Paraganglioma With Invasion Into Hepatic Veins and Suprahepatic Vena Cava: A Surgical and Anesthesia Management Challenge

Primary hepatic functional paraganglioma is a rare form of extra-adrenal catecholamine-secreting tumor. Definitive treatment of functioning paraganglioma is challenging because of the critical location of the tumor frequently in close proximity to vital structures and risk of excessive catecholamine release during operative manipulation. We report the multidisciplinary management approach for a case of unresectable primary hepatic functional paraganglioma with invasion into the hepatic veins and suprahepatic vena cava.To our knowledge, this is the first report showing that orthotopic liver transplantation is curative for patients with unresectable primary hepatic paraganglioma. For locally advanced unresectable hepatic paraganglioma that involves the intrapericardial vena cava, a meticulous pre- and intraoperative medical management and transabdominal intrapericardial vascular control of the suprahepatic vena cava during orthotopic liver transplantation allows for complete extirpation of the tumor and achieves optimal outcome.