Novel technique for suprahepatic vena cava reconstruction in rat orthotopic liver transplantation

In previous studies, the suture technique and the cuff method were applied to anastomoses of the suprahepatic vena cava (SHVC) in rat orthotopic liver transplantation. However, the anastomosis of SHVC is difficult during transplantation because of the short length of the SHVC. Here, we developed a novel method for anastomoses of SHVC, using a veno-lined stent technique. The veno-lined stent for SHVC anastomosis was prepared after the donor operation. The special veno-lined stent was a 4.0-mm-long polythene tube in which a venous segment from the donor was lined. During the recipient operation, the donor SHVC was anastomosed end-to-end to the recipient SHVC, using the veno-lined stent. Anastomoses of the portal vein and infrahepatic vena cava were performed using a cuff technique. Continuity of the bile duct was established using a stent. The hepatic artery was ligated, and the graft was not arterialized. As controls, the unlined stent, the suture technique, and the cuff method were also used for SHVC anastomoses, respectively, as three control groups with the identical procedures above. In total, 30 orthotopic liver isografts were performed using the veno-lined stent technique. The survival rate was 90% (27/30) after 1 week and 70% (21/30) after 2 months, with normal hepatocellular function. The SHVC anastomosis using a veno-lined stent took 10 +/- 2 (mean +/- SD) min. The anhepatic phase, recipient operative time, and complete operation time were about 14 +/- 2 min, 40 +/- 5 min, and 120 +/- 10 min, respectively. However, in the nonlined stent control group, a total of 20 orthotopic liver isografts used the nonlined stent for SHVC anastomoses, and all failed because of venous thrombosis in SHVC; none survived over 1 week. In the suture technique control group, 40 orthotopic liver isografts were performed using a suture technique for SHVC anastomoses. The results showed no significant difference with those of the veno-lined stent method. But in the cuff method control group, of all 20 orthotopic liver isografts performed using the cuff method for SHVC anastomoses, 10 failed because of failed ligation on the anastomostic site. The survival rates at 1 week and 2 months postoperatively were significantly different from those of the veno-lined stent method. The veno-lined stent technique provides a novel, simple, and reliable method for SHVC anastomoses. It avoids bleeding during suture and the ligation difficulties found with the cuff method. The operation's success rate is satisfactory. This model is successful, and could be applied in various experimental studies.     

Evaluation, operative management, and outcome after liver transplantation in children with biliary atresia and situs inversus.

INTRODUCTION: Biliary atresia, a common indication for liver transplantation, can be associated with situs inversus. Our experience with liver transplantation in children (n = 6) was reviewed retrospectively. PATIENTS AND METHODS: Preoperative duplex sonography, computerized tomography, and visceral angiography were obtained. Vascular anomalies identified included preduodenal portal vein (6/6), interrupted inferior vena cava (5/6), and aberrant hepatic artery (4/6). RESULTS: The liver graft was placed in a midline position. Venous continuity was achieved by donor suprahepatic inferior vena cava to recipient hepatic cloaca and direct end-to-end portal anastomosis. The donor infrahepatic inferior vena cava was oversewn. Arterial continuity was restored using either a direct branch-patch anastomosis (3/6) or a supraceliac aortic interposition graft (3/6). In retrospect, preoperative diagnostic work-up was noncontributory and outcome was not complicated by pre-existing situs inversus. CONCLUSION: Situs inversus in liver recipients requires operative technical modifications, but does not change outcome. Furthermore, extensive preoperative work-up should be avoided.     

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.     

Replacement of the vena cava with aortic graft for living donor liver transplantation in budd-Chiari syndrome associated with hydatid cyst surgery: a case report

A 12-year-old girl, operated because of a hydatid cyst of the liver, with Budd-Chiari syndrome was evaluated for postoperative development of ascites and paraumbilical varicose veins. A vena caval stent was placed for the relief of inferior vena caval obstruction. The patient was admitted because of progressive deterioration in ascites and liver functions. Imaging techniques showed degeneration adjacent to the right hepatic vein in liver segments 7 to 8, a partially calcified 5-cm hydatid cyst, and a thrombosis in the inferior vena cava was that addressed with a 10-cm metal stent. A living donor segments 2 to 3 liver transplantation was obtained from the patient's mother. After completion of the donor operation without complications, the vena caval stent was removed following the recipient hepatectomy. Suprarenal flow continued after resection of the fibrotic vena cava and placement of a cadaveric cryopreserved aortic graft for the vena cava, anastomosed between the suprarenal and subdiaphragmatic segments of the vena cava. An end-to-side anastomosis was performed between the left hepatic vein of the donor liver and the aortic graft. There was no complication and the patient was discharged on postoperative day 19. Follow-up Doppler ultrasonography showed the aortic vena caval graft to be open, along with the hepatic/portal vein and hepatic artery. This case demonstrated that operations for liver hydatid cyst surgeries can iatrogenically induce Budd-Chiari syndrome; a cryopreserved aortic graft can be an alternative to ensure the continuity of the vena cava in living donor liver transplantation.     

猪辅助性部分肝移植模型制作及比较

目的建立猪的辅助性部分肝移植模型,观察其肝功能和术中血流动力学变化。方法 24头健康良种家猪,体质量23-30 kg,被随机分为供体(n=12)和受体(n=12)。气管插管 全麻,硫喷妥钠静脉维持。移植前切除受体肝左叶,供肝右叶作为植入肝。预实验2例行经体位转流的原位辅助性部分肝移植,对照组(5例)行简易转流下的原位辅助性部分肝移植。模型组(5例)行异位辅助性部分肝移植, 供肝被植入受体肝下间隙,供肝肝上下腔静脉与受体肝下下腔静脉端侧吻合,供肝门静脉与受体门静脉行端侧吻合,供肝肝动脉与受体脾动脉行端端吻合。供肝胆总管置管外引流。结果预实验中行体位静脉转流的原位辅助性部分肝移植的2例受体在肝上下腔静脉阻断后很快陷入血流动力学紊乱死亡。5例行简易静脉转流的原位辅助性部分肝移植的受体,2例在24 h内死亡,1例28 h,2侧超过48 h。而模型组受体 5例中有4例存活超过24 h。AST,ALT指标手术开始至术后24 h呈持续升高。模型组术中血流动力学较其他组稳定。结论该辅助性肝移植模型简明易建且具有不需静脉转流等优点,为研究辅助性部分肝移植原肝和供肝功能及血流变化提供了理想的平台。     

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.     

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。     

120例大鼠原位肝移植报道

目的建立一个稳定的大鼠原位肝移植模型,探讨其术中和术后并发症的预防。方法在Ka-mada“二袖套法”吻合血管的基础上进行改良。供体改经腹主动脉进行肝脏冷灌注;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,胆总管采用单管内支架胆管端端吻合法。结果共施行大鼠原位肝移植120例,手术成功率为96.7%。大鼠1周存活率为95%,3月存活率达90%。结论娴熟细致的外科操作提高了手术成功率,受体无肝期的长短是决定动物存活的关键。     

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目的：分析10例活体肝移植术中的血管变异，总结其外科处理经验，进一步提高手术成功率，减少并发症。方法：2001年1月至12月，行活体肝移植10例，其中左半肝8例，左外叶1例，右半肝1例，供肝者均为其母，经术中B超及胆管造影以确定肝切线。供体单支肝动脉分支与受体肝动脉吻合，两支肝动脉分别与受体肝左、右动脉吻合。门静脉分支与受体门静脉主干吻合。供体肝静脉与受体下腔静脉行端侧吻合。胆管重建均采用肝管分支与受体胆总管端端吻合，置T管引流。结果：10例活体肝移植，1例因肝动脉血栓形成，术后5天需次肝移植；1例发生排斥；其余8例均康复出院，5例已上学。结论：活体肝移植术中血管重建技术是其重要环节，术前和术中了解供受体解剖变异并正确处理，可减少术后血管和胆道的并发症。     

Auxiliary liver transplantation in acute liver failure in the rat – an illustrated description of a new surgical approach

INTRODUCTION: To investigate auxiliary liver transplantation successfully in rats suffering from acute liver failure, we developed a new surgical approach. METHODS: A 70% hepatectomized liver graft was implanted into the right upper quadrant of the abdomen. The donor portal vein was anastomosed with the recipient's right renal artery using the splint technique. The donor infrahepatic vena cava was attached onto the recipient vena cava end to side. The bile duct was implanted into the duodenum.     

大鼠原位肝移植模型的手术技巧及并发症的预防

目的 探讨建立一个稳定的大鼠原位肝移植模型的手术技巧以及术中和术后并发症的预防。方法 在Kamaka用“二袖套法”吻合血管的基础上进行改良。供体改经腹主动脉进行肝脏冷灌注；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，胆总管采用单管内支架胆管端端吻合法。结果 共施行大鼠原位肝移植360次，手术成功率为91．3％。非干预组中，同系移植大鼠1周存活率为86．5％，3个月存活率达80．7％。结论 熟练的显微外科技术、细致的手术操作是预防术中和术后并发症的先决条件。受体无肝期的长短是决定动物存活的关键。     

A simple method of orthotopic liver transplantation in dogs.

Orthotopic liver transplantations were performed by one team in 18 dogs using a cuff method to anastomose the portal vein, the suprahepatic vena cava and the infrahepatic vena cava without external or internal shunts. Total and warm ischemic times of donor liver averaged 124 and 32 minutes, respectively. The average occlusion time of the portal vein and the infrahepatic vena cava were 9.7 and 13.9 minutes, respectively. During this time, uncontrolled hypotension, petechiae or hemorrhagic enterogastritis did not develop. Sixteen of 18 dogs survived more than five days, and five dogs lived more than three weeks. The cause of death was not related to the cuff method in any instance. This approach proved to be a technically simple and satisfactory procedure.     

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。     

门静脉-下腔静脉吻合术预防活体肝移植术后小肝综合征3例报道

目的探讨门静脉-下腔静脉吻合术用于预防活体肝移植术后小肝综合征(small-for-size liver syndrome,SFSS)的效果。方法 3例活体肝移植均采用不含肝中静脉的右半肝作为移植物。术中发现实测移植物(肝)重量/受体的体质量(体重)的比值(graft to recipient weight ratio,GRWR)为0.58%、0.77%及0.71%,均<0.8%,符合小移植物的诊断。处理:首先吻合肝静脉流出道,其次吻合门静脉,将受体门静脉右支与移植肝门静脉右支端端吻合,将受体门静脉左支与下腔静脉行端侧吻合达到门腔分流的作用,之后按顺序吻合动脉和胆道。术中均未行脾静脉结扎或脾切除等处理。术后定期随访。结果 3例患者术后均未发生SFSS并顺利出院,出院时间分别为术后25d、34d及56d。移植肝功能逐步好转,术后1d门静脉流速理想。移植肝增长良好。门静脉-下腔静脉短路通畅时间:除1例通畅持续仅104d,其余2例持续通畅。结论 LDLT术中进行门静脉-下腔静脉吻合术可以及时有效预防小移植物背景下的SFSS,受体门静脉左支与下腔静脉行端侧吻合的分流技术安全可靠。     

Surgical technique for combined intestine-auxiliary liver transplantation in rats: development of a new microsurgical model.

Combined liver-intestine transplantation is an evolving procedure, and auxiliary liver transplantation has several advantages over standard orthotopic liver transplantation. We present a new model of combined intestine-auxiliary liver transplantation in rats. Total small bowel and 60% liver were harvested en bloc. An aortic segment that contained the celiac axis and superior mesenteric artery ensured blood supply to the graft. Venous drainage of the grafted intestine was achieved via the intact portal vein of the graft. The infrahepatic vena cava was cut at different levels during the modification period and at the oblique level of the left renal vein in consecutive series. Revascularization was accomplished by end-to-side anastomosis of the aorta and of the infrahepatic vena cava. The recipient small bowel was resected and the intestine continuity restored by anastomosis. Total operation time averaged 130 min. The overall survival rate of 3 months in the consecutive series was 80% (16/20). Exploratory laparatomy and histologic study in 3 rats on 90 days after transplantation revealed normal and viable grafts. Liver function was normal and both grafted liver and intestine showed normal histologic architectures in 5 rats observed for 12 months after transplantation. The present model is reproducible and allows preclinical research on several aspects of experimental combined intestine-auxiliary liver transplantation.     

Arterial reperfusion in human orthotopic liver transplantation by anastomosis of the celiac trunk to the right or left hepatic artery of the recipient

Fifteen orthotopic liver transplants were performed from 23 April 1986 to June 1987 in 14 patients (age range 3-56 years). In 12 transplants, extracorporeal bypass was used. The installation was effected by suprahepatic and infrahepatic cava-caval and portaportal anastomoses. Arterial anastomosis was realized after reperfusing the graft through the vena porta. In 13 transplants the donor celiac trunk was anastomosed to the receptor's right hepatic artery. In one ten year-old girl, the donor celiac trunk was anastomosed to the left hepatic artery. In one patient who underwent retransplantation for rejection, the donor organ had two separate hepatic arteries and the right and left hepatic arteries were respectively anastomosed to the right and primitive hepatic arteries of the receptor. All patients were followed up periodically by Doppler echography and trimethyl-Br IDA 99 mTc scan, which, consistently confirmed the permeability of the anastomosis and dependent vessels, and the good perfusion and function of the grafts, which were free of infarcted areas. Three patients died at 30 and 31 days and postmortem studies demonstrated vascular permeability. Angiography was performed in one patient, evidencing a good vascular caliber in the hepatic arteriography.     

Orthotopic liver retransplantation in rats

A surgical experience with a method of rat orthotopic liver retransplantation (OLRT), and a preliminary study of immunological responses after OLRT are reported. OLRT was performed on the same recipient after the first orthotopic liver transplantation (1st-OLT) according to our original (Kamada's) cuff method. Replacement of the portal vein (PV) and infra-hepatic vena cava (IHVC) cuffs was not technically difficult. However, there were no survivors from the first 6 retransplanted rats, mainly due to complications from defective supra-hepatic vena cava (SHVC) anastomoses. Unlike the human intra-abdominal SHVC, the posterior wall of the intraabdominal SHVC in rats is too short and fragile to perform an end-to-end anastomosis twice between donor and recipient SHVC. For a second group of seven retransplants, a modification of the SHVC anastomosis was made between donor and recipient SHVC in conjunction with the recipient's cuff diaphragm. This enabled reanastomosis to be secure, resulting in the improved 1-week survival after isogeneic OLRT (85.7%). This OLRT model has been applied to the fully allogeneic combination for several immunological studies and led to novel findings. Thus, an experimental model of a rat orthotopic liver retransplant model has the potential to allow more valuable insights into the immunological study of chronic rejection, sensitization and chimerism following liver retransplantation. © 1995 Wiley-Liss, Inc.     

大鼠原位肝移植模型的手术操作技巧探讨

目的 建立一个稳定的大鼠原位肝移植模型,探讨其手术技巧。方法在Kamada“二袖套法”的基础上进行改良。供体改经腹主动脉进行肝脏冷灌注;肝上下腔静脉用连续缝合法吻合,门静脉和肝下下腔静脉用袖套法吻合．胆总管采用单管内支架胆管端端吻合法。结果共施行大鼠原位肝移植140例,无肝期平均11min．手术成功率为97％,大鼠1周存活率为95％。结论改良的两袖套法具有操作简便、无肝期短、手术成功率高、大鼠术后存活时间长的优点,是大鼠原位肝移植的理想术式。娴熟细致的外科操作、受体无肝期的长短是决定动物存活的关键。     

小型猪原位肝移植模型的建立与评价

目的 探讨建立放弃静脉转流的小型猪原位肝移植模型的可行性。方法 选用广西巴马小型猪(3-6月龄,8-11kg)为实验动物,共实施原位肝移植10例次。供体肝脏游离、冷灌注、切取、修整以及UW保存按常规方法进行。受体术中肝脏游离后夹闭肝上、肝下下腔静脉和门静脉并切除受体肝脏,各血管断端与供肝相应血管进行端端吻合,肝上下腔静脉和门静脉吻合完毕即开放肝脏血流,在此过程中未使用静脉转流,此后吻合肝动脉、胆管。结果 本组10例次肝移植手术后一周存活率90％(9/10),无肝期时间31.3±2.67min,无肝期血压显著下降(MAP4.5±1.58kPa)但肝血流开放后能较快恢复并渐趋平稳。结论 本组结果表明,非静脉转流条件下的小型猪肝移植模型是一操作方便、易于复制同时又具有较好重复性和稳定性的大动物肝移植模型,能应用于肝移植的系列实验研究。     

大鼠原位肝移植模型的建立及术式改进

目的探讨用双袖套法建立大鼠原位肝移植模型的手术改进方法. 方法在Kamada等的袖套法吻合血管的基础上进行改进,供体改经腹主动脉进行肝脏冷灌注,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,胆总管采用单管内支架胆管端端吻合下进行原位肝移植360例(次). 结果施行大鼠原位肝移植其供体手术时间(31.2±5.0)分钟,供肝修整时间(12.0±3.0)分钟,受体手术时间(45.0±5.5)分钟,无肝期(20.0±2.5)分钟,手术死亡31例,其中出血12例,肝下下腔静脉血栓8例,肝上下腔静脉回流不畅7例,袖套扭转或脱落4例.术后成活2天以上329例,成活率为91.4%.非干预组(非药物治疗组)1周存活率达86.5%. 结论改进的大鼠原位肝移植术操作简便,手术成功率高,可作为肝移植实验可靠、稳定的动物模型.