Hepatic Venous Outflow Obstruction in Adult Deceased Donor Liver Transplantation: Classic Piggyback Implantation Versus a Modified Technique that Widens the Ostium of the Recipient's Left and Middle Hepatic Veins

BackgroundThe classic piggyback technique uses the union of the 3 hepatic veins to perform the cavo-caval anastomosis. However, due to the lateral localization of the right hepatic vein, the partial clamping of the vena cava in this technique significantly reduces the venous return to the right atrium. To avoid this, we adopted in 2015 a modified piggyback technique, in which we use the common trunk of the middle and left hepatic veins and also perform a lateral incision toward the right in the anterior wall of the vena cava in order to widen the final ostium of the cavo-caval anastomosis. The aim of the study was to analyze the incidence of hepatic venous outflow obstruction between those 2 techniques.MethodsRetrospective study of liver transplant recipients undergoing venography for suspected hepatic venous outflow obstruction from January 2009 to June 2021. Patients undergoing transplantation with living donors or split grafts and pediatric cases were excluded from the study.ResultsFrom January 2009 to December 2014 and from January 2015 to June 2021, 587 (group 1) and 730 (group 2) deceased-donor liver transplants were performed with the classic and the modified piggyback techniques, respectively. The incidence of cases with suspected hepatic venous outflow obstruction in groups 1 and 2 were 1.87% (n = 11) and 0.95% (n = 7), respectively (P = 0,15). The number of confirmed patients with outflow blockage that required endovascular treatment during venography in groups 1 and 2 were 4 (0.68%) and 5 (0.68%), respectively (P = 0,31).ConclusionsThis modified piggyback technique did not increase the incidence of hepatic venous outflow obstruction at our service.     

Hanging Hepato-Atrial Anastomosis in Deceased-Donor Liver Transplantation for Budd-Chiari Syndrome With Extensive Vena Cava Obliteration: A Case Report

Introduction

Although outcomes of liver transplantation (LT) have improved as the result of progress in surgical procedures, a failure to restore sufficient graft outflow may yield fatal consequences including graft dysfunction and even graft loss to date. In particular, patients with pre-existing obliterated venous drainage, such as those with Budd-Chiari syndrome (BCS), are at high risk of having venous complications followed by conventional LT. In selected cases, the transplant surgeons are compelled to modify the surgical procedures of LT from the conventional procedure.

Efficiency of Transluminal Angioplasty of Hepatic Venous Outflow Obstruction in Pediatric Liver Transplantation

Background

Our aim in this study was to evaluate long-term efficiency of hepatic venous balloon angioplasty (BA) and stent placement (SP) for hepatic venous outflow obstruction (HVOO) in pediatric liver transplantation (LT).

An Alternative Method of Reconstruction of Hepatic Venous Outflow in Domino Liver Transplantation

The double piggyback technique has been proposed for domino liver transplantation. To make this possible, it is necessary to reconstruct the venous outflow of the domino liver graft on the back table. We describe an alternative method of reconstruction of hepatic venous outflow, in which a neocaval segment is obtained using both common iliac veins from the cadaveric donor.     

Continuous Versus Interrupted Suture for Hepatic Artery Anastomosis in Liver Transplantation: Differences in the Incidence of Hepatic Artery Thrombosis

Background

Hepatic artery thrombosis (HAT) is a serious complication after orthotopic liver transplantation (OLT) and remains a significant cause of graft loss. HAT following OLT has been reported in 3% to 9% of patients. Among the surgical factors considered to be associated with HAT, arterial reconstruction might be the most important. The goal of this study was to compare the incidence of HAT between interrupted suture (IS) and continuous suture (CS) techniques during hepatic artery reconstruction in liver transplantation.

Methods

We performed a retrospective analysis of 200 consecutive liver transplantations occurring between May 2002 and December 2006, including medical records for: age, gender, cold ischemic time, warm ischemic time, type and number of arterial anastomosis. Hepatic artery anastomoses were performed using a 7-0 prolene with a running CS in the first 105 patients (CS group), and with an IS in the last 95 patients (IS group).

Results

Statistical analysis of age, gender, cold and warm ischemia time, and number of hepatic artery anastomoses was not different between the CS and IS groups. Eleven episodes of HAT were identified in the CS group (10%) and two episodes (2%) in the IS cohort, a significant difference (P = .0173).

Conclusions

Our results suggested that IS might be a better choice for hepatic artery anastomosis with a lower incidence of HAT.     

Standardization of the Side-to-Side Cavo-Caval Anastomosis in Orthotopic Liver Transplantation Based on the Causal Analysis of Outflow Obstruction

BackgroundAlthough liver transplantation is widely accepted as the therapeutic strategy for end-stage liver failure, complication of hepatic venous outflow obstruction remains lethal. Currently, ensuring a single wide orifice in both the graft and recipient inferior vena cava has been proposed to avoid hepatic venous outflow obstruction with no theoretical concept.MethodsWe herein report a standardization technique for the reconstruction of the hepatic vein based on the causal analysis.ResultsDuring the put-in process, the graft must be positioned in contact with the recipient diaphragm and slightly pushed to the cranial direction to simulate the state after abdominal closure. Because there is no extra space between the graft and diaphragm, the graft could not rotate about the anastomotic site of the inferior vena cava toward the diaphragm after abdominal closure as the intestinal pressure increases, and accordingly hepatic venous outflow obstruction does not develop.ConclusionsWith this concept, all transplant surgeons can successfully and easily perform hepatic vein reconstruction without total clamping of the inferior vena cava and without outflow block.     

Hepatic Artery Intimal Dissection During Living Donor Liver Transplantation: A New Modified Approach

Ensuring optimal arterial flow in solid organ transplantation is very important. Insufficient flow causes important problems such as bile duct problems, intrahepatic abscess formation, and organ loss. Arterial intimal dissection is an important factor that negatively affects organ blood flow. In this study, hepatic artery dissections that we detected in patients who underwent living donor liver transplantation in our clinic were defined, and the microvascular intima-adventitial fixation technique, which can be considered a new approach, was described.     

Low Incidence of Hepatic Artery Thrombosis After Hepatic Artery Reconstruction During Liver Transplantation

Background

Hepatic artery thrombosis (HAT) remains an important cause of graft loss after liver transplantation. HAT can be caused by technical, hemodynamic, or immunologic factors. Bench reconstruction of anatomical variants of the hepatic artery is considered to fore a major risk related to HAT. The purpose of the study was to analyze the influence on HAT of hepatic artery vascular reconstruction.

Methods

We retrospectively analyzed 341 donor forms completed between January 2004 and December 2007. Vascular reconstruction was defined as an additional anastomosis between donor hepatic arteries, which was required to fully revascularize the graft. Any incident of HAT was confirmed by angiography and intraoperatively during retransplantation. Fisher's exact test and 95% confidence intervals (CI) were applied for statistical analysis.

Results

Among 341 grafts hepatic artery anomalies observed, variations were recorded in 92 cases (26.9%), of whom 35.9% required hepatic artery reconstruction. HAT was diagnosed in 3% (1/33) hepatic reconstructions (CI, 0.1%-15.8%) compared with 1.6% of grafts (5/308) that did not required hepatic reconstruction (P ≤ .45). The 1 case of hepatic thrombosis (1/59) accounting for 1.6% among the group with hepatic anomalies without reconstruction (CI, 0.04%-9.1%).

Conclusion

A single hepatic reconstruction was a nonsignificant factor for HAT. Hepatic artery reconstruction did not increase the risk of HAT compared with the normal blood supply. Hepatic artery anomalies did not significantly increase the incidence of HAT compared with the group of patients without arterial variations.     

Portoumbilical Anastomosis as a Simple Method of Transient Portosystemic Shunt During Liver Transplantation

Background

This article describes a new method of transient intraoperative portosystemic shunting, Splachnic edema after portal cross-clamping can be a dangerous complication during the anhepatic phase of the liver transplant operation. The current method seeks to avoid this problem, without the use of external venovenous bypass pump, by a temporary portocaval shunt, with retrohepatic cava preservation as first described experimentally in dogs by Fonkalsrud et al in 1966.

Methods and Results

Among 227 liver transplant operations, we utilized a transient portosystemic shunt in 29 cases. The indication to perform a temporary shunt in all cases was the development of splachnic edema. In 3 instances, we performed a portoumbilical anastomosis using a prominent umbilical vein. The other 26 procedures employed the usual portocaval shunts. In these cases, splachnic congestion and onset of edema developed after cross-clamping of the round ligament and the portal vein, which resolved after the portoumbilical anastomosis.

Discussion

The flow in the shunt was in all cases greater than 1 L/min. The most important risk factor for the development of splachnic edema was the presence of a patent umbilical vein, which occurred in 34.5% of shunted patients.

Conclusion

The use of a patent umbilical vein to perform a portoumbilical shunt was an effective, easy method to decompress the splachnic area, avoiding dangerous congestion and edema.     

Impact of Microsurgical Anastomosis of Hepatic Artery on Arterial Complications and Survival Outcomes After Liver Transplantation

Hepatic artery (HA) complications after liver transplant (LT) can lead to biliary complications, graft failure, and mortality. Although microsurgery has been established to improve anastomotic outcomes, it prolongs surgical time and has not reached widespread adoption at all transplant centers. We investigated the incidences of arterial, biliary complications and outcomes after using microsurgery to anastomose HA during LT. Retrospective cohort of consecutive LT performed from 2006 to 2018 was reviewed for operative details and postoperative outcomes. Cox-regression models were used to investigate the relationship between variables and outcomes. Eighty (62.5%) LTs (Group 1) were performed without and compared with 48 (Group 2) with microsurgical anastomosis of HA. Both groups were comparable in terms of arterial and biliary anastomoses performed. Incidence of early HA thrombosis was similar (6.2% vs 2.1%, P = .28). Group 2 had lower incidence of short- and long-term arterial complications, especially amongst living donor liver transplantations (LDLT) (5.3% vs 35.0%, P = .022). On multivariate analysis, microsurgery was associated with lower risk (hazard ratio [HR] 0.09, 95% confidence interval [CI] 0.01-0.71) of, and LDLT had higher risk (HR 4.23, 95% CI 1.46-12.27) of arterial complications. Biliary complications were associated with LDLT (HR 3.91, 95% CI 1.30-11.71) and dual biliary anastomoses (HR 5.26, 95% CI 1.15-24.08) but not with occurrence of HA complications. Worse patient survival was associated with the occurrence of any HA complication (HR 4.11, 95% CI 1.78-9.48). Hepatic arterial complications can be reduced using microsurgical techniques for the anastomosis, resulting in improved patient survival outcomes after liver transplantation.     

Biliary Anastomosis in Living Related Liver Transplantation Using the Right Liver Lobe: Techniques and Complications

Since the introduction of adult-to-adult living donor liver transplantation using the right lobe of the liver, biliary problems have led the list of complications resulting in postoperative morbidity. We report our experience with the first 30 living donor liver transplantations performed in our institution from August 1998 to January 2000. Patients were 21 men and 9 women, with a mean age 45 ± 16 years. Mean recipient weight was 65.1 ± 17.9 kg, mean graft weight was 877 ± 146 g, and the mean graft-recipient weight ratio was 1.5 ± 0.6. Patient and graft survival rates were 83.3% and 80%, respectively. Biliary anastomosis was either an end-to-end hepaticocholedochostomy with a T-drain or hepaticojejunostomy. Mean follow-up was 217.4 ± 149.8 days. The overall complication rate was 26.6% (8 of 30 procedures) and was directly correlated to the type of anastomosis and number of bile ducts. Surgical revision was necessary in all cases. Biliary complications were not the primary cause of graft loss. Adult living donor liver transplantation using the right lobe is a successful procedure, with graft and patient survival similar to those in cadaver full-organ transplantation. Postoperative morbidity, mainly caused by biliary leak, was directly related to the number of ducts and type of anastomosis. With increasing experience, we have better defined our plane of transection on the hilar plate, with the goal of obtaining only 1 biliary duct for the anastomosis. We also improved our parenchymal transection technique, which resulted in a decreased incidence of leak at the cut-surface area. (Liver Transpl 2000;6:710-714.)     

Liver Transplantation for Giant Hepatic Hemangioma: A Systematic Review

Introduction

Despite their benign nature, liver hemangiomas (LH) are lesions that can cause major complications requiring intervention. Liver transplantation (LT) has been suggested as an effective treatment option in selected patients with giant LHs causing severe symptoms and cannot be treated otherwise. The aim of our study was to investigate the indications, aspects and post-operative outcomes of patients with a LH who underwent LT.

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.     

Blood Flow During Obstruction to the Venous Effect of Portacaval Transposition on Hepatic Outflow from the Canine Liver

When portacaval transposition (PCT) was performed in dogs in combination with a complete hepatic venous outflow block (COB) procedure, estimated hepatic blood flow (EHBF) declined steadily. Four weeks after this combined procedure mean flow was only 46% of the value obtained 3 days after operation, but this did not prevent the development of ascites which occurs in dogs with COB alone. Complete reversal of portal flow was demonstrated in the longest surviving dog. When PCT was performed in dogs with established partial outflow block EHBF remained at preoperative levels whether portal hypertension was present or not prior to the second operation. This maintenance of hepatic blood flow was due to continuing venous flow into the portal bed. It would appear that PCT is probably of little value as a treatment for portal hypertension and bleeding oesophageal varices in cases of advanced cirrhosis, but may be of some benefit in a few selected cases where the hepatic lesion is less severe.     

Incidence of Donor Hepatic Artery Thrombosis in Liver Grafts Recognized During Organ Procurement and Backtable: A Rare but Treacherous Pitfall In Liver Transplantation

IntroductionDonor hepatic artery thrombosis (dHAT) identified during liver procurement and backtable is a rare and little-reported event that can make liver transplants unfeasible.MethodsThis is a retrospective study of dHAT identified during liver grafts procurements or backtable procedures. All grafts were recovered from brain-dead donors. The demographic characteristics of the donors and the incidence of dHAT were analyzed. The data were also compared to a cohort of donors without dHAT.ResultsThere was a total of 486 donors during the study period. The incidence of dHAT was 1.85% (n = 9). The diagnosis of dHAT was made during procurement in 5 cases (55.5%) and during the backtable in 4 (44.4%). Most donors were female (n = 5), with an average BMI of 28.14 ± 6.9 kg/m², hypertensive (n = 5), and with stroke as cause of brain death (n = 8). The most prevalent site of dHAT was a left hepatic artery originating from the left gastric artery (n = 4). Of the 9 cases reported, 2 livers were used for transplantation, and 7 were discarded. Comparing those cases to a cohort of 260 donors without dHAT, we found a higher incidence of anatomic variations in the hepatic artery (P = .01) and of stroke as cause of brain death (P = .05).ConclusionThe occurrence of dHAT before liver procurement is a rare event, however it may become a treacherous pitfall if the diagnosis is late. Grafts with anatomic variations recovered from women with brain death due to stroke and with past history of hypertension seem to be at a higher risk of presenting dHAT.     

Arterial Anastomosis in Liver Transplantation for Rendu-Osler-Weber Disease: Two Case Reports

Liver transplantation (LT) in patients with hereditary hemorrhagic telangiectasia (HHT), or Rendu-Osler-Weber, disease is a problematic procedure. In patients with hepatic involvement due to clinically significant arterovenous malformations, there is high risk of intraoperative bleeding and intra- or perioperative complications. Some surgical corrections have been proposed for venous problems, concerning the vena caval anastomosis. A common finding in HHT is arterial enlargement of the celiac trunk and of the common hepatic artery. We report 2 cases of LT in HHT where the arterial anastomosis was successfully performed using the splenic artery of the recipient, which shows less tendency for enlargement than the celiac trunk.     

Technical Refinement to Prevent Hepatic Outflow Disturbance in Right Lobe Living Donor Liver Transplantation: The New Simplified One-Orifice Venoplasty Technique

Middle hepatic vein (MHV) reconstruction is often essential to avoid hepatic congestion and serious graft dysfunction in living donor liver transplantation (LDLT). This article introduces the evolution of our MHV reconstruction technique and the excellent outcomes of a new simplified one-orifice venoplasty. We compared clinical outcomes among 3 types of one-orifice techniques through a retrospective review of 378 recipients who underwent LDLT using a modified right lobe graft at our institution from January 2008 to December 2018; group I (n = 34) received separate outflow reconstruction, group II (n = 166) received the one-orifice technique to create a wider single outflow with patchwork, and group III (n = 178) received the more simplified one-orifice technique in which neo-MHV was reconstructed into the right hepatic vein without patch venoplasty. Patient demographic characteristics did not differ significantly among the 3 groups, but cold ischemic time and operative time in groups II and III were significantly shorter than those in group I. Moreover, the early patency rates of MHV in groups II and III were higher than those in group I. In particular, group I received an MHV or right hepatic vein stenting more frequently than group II or III during the early posttransplant period. In conclusion, this new simplified one-orifice technique could be an effective method to overcome technical difficulties and the outflow disturbance during right lobe LDLT without complex benchwork to create a large outflow.     

同种原位肝移植肝脉重建技巧

目的：探讨和总结同种原位肝移植术中肝动脉重建技术。方法：回顾性分析我院近一年来所施行18例原位肝移植术中肝动脉重建方式和技巧。结果15例行供受体肝固有动脉端端吻合,2例供体肝总动脉与受体肝固有动脉吻合,1例供体总动脉与受体脾动脉吻合。术后彩色色普勒超声监测显示肝动脉血流通畅,均未发现有血栓菜成或肝动脉狭窄,全部病例未发生胆道并发症。结论：成功的肝动脉重建技术防止肝移植术后肝动脉血栓形成或肝动脉狭窄的关键。     

肝动脉变异与肝移植

目的总结肝移植中供体及受体肝动脉变异情况与重建方式。方法回顾我院2002年3月～2005年12月107例肝移植供体与107例受体肝动脉变异情况及重建方式。术后应用Doppler超声、胆道镜及介入方法监测肝动脉及胆道并发症的发生情况。结果107例肝移植之供、受体肝动脉(214例肝动脉),3例术中、术后死于多器官功能衰竭,有20例次肝动脉变异,经过术中良好的重建,其结果显示肝动脉及胆道并发症3例(3/19),较正常肝动脉吻合者(15/85)无显著性差异(P>0.05)。结论肝动脉变异发生率约9.35%左右,肝移植时供肝切取、修整及受体病肝切除应引起高度重视,术中良好的重建能取得好的效果。