Liver transplantation for fulminant hepatic failure without venovenous bypass and without portacaval shunting

Preservation of the caval vein during liver transplantation (OLT) has gained wide acceptance but portosystemic bypass or temporary portocaval shunt is still believed to be indicated in patients with fulminant hepatic failure. Herein we have described our initial experience with piggyback OLT without venovenous bypass and without portocaval shunting in five such patients. Division of the portal vein was always delayed until the native liver was completely dissected off the caval vein. The donor hepatic artery was anastomosed to the recipient aorta via an iliac interposition graft placed in the supraceliac position in two and at an infrarenal site in three patients. The ahepatic phase urinary output was low in the two patients in whom we applied supraceliac cross-clamping of the aorta. The mean ahepatic phase was 53 (45 to 67) minutes in four recipients who remained hemodynamically stable throughout surgery and prolonged to 5 hours in one patient due to a complicated supraceliac aortic anastomosis. Its repair resulted in hemodynamic instability, multiorgan failure, and death at 4 days following OLT. Four (80%) patients are alive in good condition with normal liver function after a mean of 12 (5 to 25) months of follow-up. In summary, liver transplantation for fulminant hepatic failure may be safely performed without venovenous bypass and without temporary portocaval shunting if the ahepatic phase is minimized and portal flow to the liver maintained up to the moment of hepatic excision. Arterial anastomosis with the supraceliac aorta prolongs the ahepatic phase and may impair kidney function: therefore, it should be avoided in these patients.     

非转流原位肝移植不同术式对麻醉管理的影响

目的比较非转流背驮式与经典式原位肝移植术(orthotopic liver transplantation,OLT)对麻醉管理的影响。方法回顾性分析2003年11月~2006年12月我院50例非转流OLT的临床资料,其中背驮式(A组)和经典式(B组)各25例,比较2组患者在围术期血流动力学、凝血状况、肝肾功能、内环境的改变及液体治疗等方面的异同。结果无肝期即刻A组平均动脉压(68±6)mm Hg显著高于B组(64±5)mm Hg(t=2.561,P=0.014),A组中心静脉压(5.4±3.3)mm Hg高于B组(3.5±2.3)mm Hg(t=2.362,P=0.022),A组心脏指数(3.7±0.8)L.min-1.m-2显著高于B组(3.2±0.6)L.min-1.m-2(t=2.500,P=0.016)。新肝期即刻A组平均动脉压(66±6)mm Hg明显高于B组(62±5)mm Hg(t=2.561,P=0.014),A组中心静脉压(8.4±4.0)mm Hg与B组(10.6±4.2)mm Hg无统计学差异(t=-1.897,P=0.064)。再灌注综合征的发生率A组(2/25,8.0%)低于B组(8...     

原位肝移植的常用手术方式及应用体会

目的探讨经典原位肝移植术、改良背驮式肝移植术、原位肝移植腔静脉成形术在临床应用中的利弊。方法对2001年10月至2004年5月实施的155例病人的159次肝移植术式进行回顾性分析，其中经典原位肝移植术94例，改良背驮式肝移植术48例（包括改良背驮＋术中门一腔静脉端侧吻合转流8例），原位肝移植腔静脉成形术17例；术中行血管架桥5例，其中因门静脉闭锁及栓塞行供肝门静脉与受体肠系膜上静脉间架桥2例，因动脉变异分支细小不能利用行供肝腹腔干与受体腹主动脉间架桥3例。159例次肝移植手术均未应用体外静脉转流技术。结果原位肝移植腔静脉成形术的手术时间、无肝期最短，术中失血输血量最少，其术中对循环和肾功能的影响与经典术式相仿。经典原位肝移植术与背驮式肝移植术相比流出道不畅发生率较低，总手术时间较短（平均少30min），但无肝期较长（平均长8min），术中及术后肾上腺出血发生率较高，对肾功能影响较大，三组术后ICU留置天数差异亦无显著性意义（P=0．542）。结论不同的肝脏移植术式各有其优缺点，术者的经验以及对术式的熟悉程度会影响手术方式的选择，从原则上讲，手术方式的选择应根据具体病情及术中情况而决定。     

Does the standard vs piggyback surgical technique affect the development of early acute renal failure after orthotopic liver transplantation?

The objective of this study was to evaluate the effect of the surgical technique on postoperative renal function during the first week after liver transplantation (OLT). We performed a retrospective study of 184 consecutive OLT. Criteria for acute renal failure were: serum creatinine >1.5 mg/dL, an increase by 50% in the baseline serum creatinine, or oliguria requiring renal replacement therapy. The distribution of patients according to the surgical technique was: standard (n=84), venovenous bypass (n=20), and piggyback (n=80). Other variables analyzed were: intraoperative requirement for blood products, treatment with adrenergic agonists, intraoperative complications, and postreperfusion syndrome. Univariate analysis showed the following parameters to be significantly related to postoperative renal failure: intraoperative fresh frozen plasma and cryoprecipitate requirements, intraoperative complications, postreperfusion syndrome, need for noradrenaline or dobutamine, standard surgical technique versus piggyback (39% vs 18%, P<.01) and venovenous vs piggyback (50% vs 18%, P<.01). Logistic regression analysis identified the following variables as having independent prognostic value: (1) Standard surgical technique vs piggyback (OR=3.3, P=.01); (2) venovenous vs piggyback (OR=4.7, P=.02); and (3) >20 U cryoprecipitate requirement (OR=1.04, P=.01). In conclusion, compared with the piggyback technique, the standard surgical technique appears to be an independent risk factor for postoperative acute renal failure. When venovenous bypass is used in patients who do not tolerate trial clamping of inferior vena cava, it does not reduce the incidence of postoperative renal failure. Finally, the piggyback technique significantly reduces the probability of acute renal failure after liver transplantation.     

Polycystic Liver Disease and Liver Transplantation: Single-Institution Experience

Adult polycystic liver disease (PLD) can cause massive hepatomegaly leading to pain, caval obstruction, and hemorrhage. Many surgical techniques including aspiration, fenestration, and resection have been used to treat PLD. In addition to substantial morbidity and mortality, conservative surgery may have limited success, and palliation may be temporary. With improved results of liver transplantation, it has become the definitive treatment for PLD. We retrospectively reviewed our experience in patients with PLD between 1998 and 2007. Thirteen patients underwent liver only or liver-kidney transplantation. All surgical procedures were performed with preservation of the recipient inferior vena cava and without venovenous bypass (piggyback technique). Our patients experienced a high rate of perioperative morbidity. However, long-term patient and graft survival were excellent.     

91例肝移植手术方式分析

目的:探讨经典原位肝移植术、改良背驮式肝移植术和原位肝移植腔静脉成形术在临床应用中的利弊。方法:对2001年10月至2003年8月实施的91例肝移植术式进行总结,其中经典原位肝移植术24例(A组),改良背驮式肝移植术43例和改良背驮加术中门鄄腔静脉端侧吻合转流8例(B组),原位肝移植腔静脉成形术16例(C组);91例肝移植手术均未应用体外静脉转流技术。结果:原位肝移植腔静脉成形术的手术时间、无肝期最短(P<0.05),且术中输血量较改良背驮式肝移植术和经典原位肝移植术少(P<0.05)。3组术后ICU留置天数无显著差异(P=0.542)。结论:经典原位肝移植术、改良背驮式肝移植术和原位肝移植腔静脉成形术是肝移植的基本术式;从趋势上看,改良背驮式肝移植术将成为主流术式;对某一个具体病例选择何种术式需根据病情及术中情况决定。     

体外静脉转流原位肝移植一例

目的 采用肝脏移植治疗直硬化的原发性肝癌。方法 在动物实验的基础上,供肝发取,４℃ＵＷ液灌注和保存。手术采用体外静脉转流肝脏移植技术。结果 手术历时１２小时,无肝期１００分钟术中血流动力学平稳,术后肾功能正常。结论肝移植治疗肝硬化肝癌本外静脉转汉是十分重要的。     

Domino liver transplantation with double piggyback: is this the best technique? A case report

Sequential or domino liver transplantation is a well-established procedure for patients with familial amyloidotic polyneuropathy (FAP). Donation for domino liver transplantation imposed the resection of the inferior vena cava along with the liver, requiring complete suprarenal vena cava clamping and usually the use of venovenous bypass. We describe a successful case in which it was possible to perform the FAP hepatectomy by the piggyback technique.     

Right lobe living donor liver transplantation with or without venovenous bypass

BACKGROUND: Venovenous bypass was considered necessary to maintain haemodynamic stability and avoid splanchnic and retroperitoneal congestion during the anhepatic phase of liver transplantation. It was essential for right lobe living donor liver transplantation (LDLT) in which the inferior vena cava needed to be cross-clamped to construct wide and short hepatic vein anastomoses. However, many complications related to venovenous bypass have been reported. This study aimed to determine whether venovenous bypass was necessary for right lobe LDLT. METHODS: Between June 1996 and June 2001, 72 patients underwent right lobe LDLT. The outcomes for the first 29 patients who had venovenous bypass during the operation were compared with those of the remaining 43 patients who did not have venovenous bypass. In patients without bypass, blood pressure was maintained during the anhepatic phase by boluses of fluid infusion and vasopressors. RESULTS: Compared with patients undergoing operation without venovenous bypass, patients who had venovenous bypass required significantly more blood, fresh frozen plasma and platelet infusion, and had a lower body temperature; their postoperative hepatic and renal function in the first week was worse than that in patients who did not have a bypass. The time to tracheal extubation was longer and the incidence of reintubation for ventilatory support was higher with venovenous bypass. Six of the 29 patients with venovenous bypass died in hospital, compared with two of the 43 patients without a bypass (P = 0.05). By multivariate analysis, the lowest body temperature during the transplant operation was the most significant factor that determined hospital death. CONCLUSION: Venovenous bypass is not necessary and is probably harmful to patients undergoing right lobe LDLT, and should therefore be avoided.     

附加腔静脉成形的背驮式原位肝移植术

目的　探讨腔静脉成形术在背驮式原位肝移植中的应用价值及在防止移植肝流出道阻塞并发症中的作用。方法　 3例终末期肝病病人选为肝移植受者。供肝的下腔静脉及受体的肝后下腔静脉 (包括肝静脉 )均作了成形术 ,在单独股 -腋静脉转流术下行改良背驮式肝移植术。结果　 3例病人术中均较平稳 ,手术时间和无肝期缩短 ,出血量减少 ,术后肝功能恢复快 ,恢复顺利 ,无并发症发生。结论　腔静脉成形术可防止背驮式肝移植肝静脉流出道阻塞 ,术中对受体的血流动力学干扰小 ,并可缩短无肝期和减少腔静脉梗阻并发症的发生。     

Pulmonary gas exchange during orthotopic liver transplantation

The aim of this study was to evaluate the efficiency of pulmonarygas exchange during the course of liver transplantation. Westudied 25 adult cirrhotic patients undergoing transplantation,performed with venovenous bypass. A significant increase inPa_o2 and a significant decrease in physiological shunt and alveolar-arterialpartial pressure difference were observed just before the startof venovenous bypass. These changes were probably caused bymodifications in respiratory mechanics, such as an increasein functional residual capacity. There were no other respiratorychanges during the anhepatic and post-anhepatic phases.     

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??Hepatic vein plasty for reconstructing graft outflow in Piggy-backy liver transplantation WANG Meng-long, LU Shi-chun, CHI Ping, et al. Liver Transplantation Center, Beijing You'an Hospital, Capital University of Medical Sciences, Beijing 100069, China
Corresponding author??WANG Meng-long,E-mail: mlwangwangml2000@yahoo.com
Abstract??Objective??To investigate the effect of the hepatic vein plasty on the graft outflow in piggy-back liver transplantation. Methods 303 orthotopic liver transplants were performed between June 2004 and November 2008. Piggy-back technique with hepatic vein plasty was used in 84 cases. Results Inferior caval vein pressures were significantly increased less in piggy-back liver transplantation than those in conventional technique without venovenous bypass , but comparable to those with venovenous bypass during anhepatic phase. No hepatic venous outflow obstruction was encountered after piggy back liver transplantation with hepatic vein plasty, and no acute renal failure developed because of this technique. Conclusion Hepatic vein plasty in piggy back liver transplantation is especially applicable to the patients with serious liver diseases requiring stable systemic hemodynamics, and with no worry about graft outflow obstruation.     

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.     

A comparison of passive and active shunting for bypass of the retrohepatic IVC

In order to provide improved shunting of caval blood around the liver for major juxtahepatic venous injuries, a modification of the venovenous bypass (active shunt) used in liver transplantation was developed. Using a porcine model, hemodynamic comparisons of active shunting with an interposed Bio-Medicus pump (group I: n = 6) and passive shunting (group II: n = 4) around the liver for 60 minutes were made. One end of the shunt was placed in the infrahepatic cava and the other end was inserted into the right atrium. Systolic blood pressure (sBP) and cardiac output (CO) were well maintained in group I. However, with passive shunting (group II), sBP fell from 134 +/- 28 to 83 +/- 28 mm Hg (p less than 0.05) and CO fell from 4.1 +/- 0.07 to 1.3 +/- 0.5 L/min (p less than 0.001) after 1 hour. The well-maintained sBP and CO in group I were associated with much better shunt flow rates than in group II (31 +/- 7 vs. 11 +/- 3 mL/kg/min) (p less than 0.001). The cause of the fall in sBP and CO with the passive shunt (group II) in spite of a well-maintained PAWP is unclear at this time. Thus, it appears that active shunting of blood around the liver using a venovenous bypass with a pump is much superior hemodynamically to passive shunting, which relies only on hydrostatic pressure.     

Two-stage liver transplantation: an effective procedure in urgent conditions

Montalti R, Busani S, Masetti M, Girardis M, Di Benedetto F, Begliomini B, Rompianesi G, Rinaldi L, Ballarin R, Pasetto A, Gerunda GE. Two-stage liver transplantation: an effective procedure in urgent conditions.
Clin Transplant 2010: 24: 122–126. © 2009 John Wiley & Sons A/S.
Abstract:  Temporary portocaval shunt and total hepatectomy is a technique used in the presence of toxic liver syndrome because of fulminant hepatic failure, hepatic trauma, primary non-function (PNF), and eclampsia. We performed this technique on four patients. An indication for anhepatic state was severe hemodynamic instability in three of them. Etiologies of these three patients were as follows: PNF after liver transplantation, ischemic hepatitis after right hepatic artery embolization, and massive reperfusion syndrome during a liver transplantation. In the fourth patient, during the liver transplantation when hepatic artery was ligated, a kidney carcinoma in the donor graft was discovered. We decided to complete the hepatectomy and to construct a temporary portocaval shunt.
Mean anhepatic phases were 19 h and 15 min. All patients survived the two-stage liver transplantation procedure without major complications. Our cases demonstrated that temporary portocaval shunt while awaiting urgent liver transplantation could be an effective "bridge" in selected patients who develop toxic liver syndrome; however, a short time between portocaval shunt and transplantation and careful intensive care managements are mandatory.     

体外静脉-静脉转流在原位肝移植术中的应用

目的　总结转流过程中的循环、代谢变化 ,并对转流的作用进行探讨　方法　对 5 4例次行静脉 静脉转流的肝移植术患者的临床资料进行分析。　结果　转流过程中及转流后心率(HR)、平均动脉压 (MAP)、中心静脉压 (CVP)、心输出量 (CO)、动脉氧分压 (PaO2 )、二氧化碳分压(PaCO2 )、血K+、Na+、Ca2 +、BUN值与转流前相比均无明显变化。pH值在转流后 15min较转流前明显降低 (P <0 0 5 ) ,乳酸水平在转流 30min、6 0min和转流后 15min比转流前均有明显增高 (P <0 0 5 )。转流 6 0min时ACT较转流前延长 (P <0 0 5 ) ,血肌酐值术后第 1天比转流前有显著提高 (P <0 0 5 )。　结论　体外静脉 静脉转流可以使肝移植手术无肝期的血液循环动力学和代谢处于相对稳定状态 ,但也存在增加手术和肝缺血时间、增加费用等一些问题。     

End-to-side caval anastomosis in adult piggyback liver transplantation

No consensus exists regarding the optimal reconstruction of the cavo-caval anastomosis in piggyback orthotopic liver transplantation (PB-LT). The aim of this study was to analyze our experience with end-to-side (ES) cavo-cavostomy. Outcome parameters were patient and graft survival and surgical complications. During the period 1995-2002 146 full-size PB-LT in 137 adult patients were performed with ES cavo-cavostomy without the routine use of temporary portocaval shunt (TPCS). In 12 patients (8%) this technique was used for implantation of second or third grafts. Veno-venous bypass was not used in any case and TPCS was performed only in eight patients (6%). One-, three- and five-yr patient and graft survival were 84%, 79% and 75%, and 81%, 74% and 69%, respectively. The median number of intraoperative transfusion of packed red blood cells (RBC) was 2.0 (range 0-33) and 30% of the patients (n = 43) did not require any RBC transfusion. Surgical complications of various types were observed after 49 LT (34%) and none of the complications was specifically related to the technique of ES cavo-cavostomy. Our experience indicates that PB-LT with ES cavo-cavostomy is a safe procedure, can safely be performed without the routine use of a TPCS, has a very low risk of venous outflow obstruction and can also be used effectively during retransplantations.     

Choice of surgical technique influences perioperative outcomes in liver transplantation

OBJECTIVE: To examine how the choice of surgical technique influenced perioperative outcomes in liver transplantation. SUMMARY BACKGROUND DATA: The standard technique of orthotopic liver transplantation with venovenous bypass (VVB) is commonly used to facilitate hemodynamic stability. However, this traditional procedure is associated with unique complications that can be avoided by using the technique of liver resection without caval excision (the piggyback technique). METHODS: A prospective comparison of the two procedures was conducted in 90 patients (34 piggyback and 56 with VVB) during a 2.5-year period. Although both groups had similar donor and recipient demographic characteristics, posttransplant outcomes were significantly better for the patients undergoing the piggyback technique. The effect of surgical technique was examined using a stepwise approach that considered its impact on two levels of perioperative and postoperative events. RESULTS: The analysis of the first level of perioperative events found that the piggyback procedure resulted in a 50% decrease in the duration of the anhepatic phase. The analysis of the second level of perioperative events found a significant relation between the anhepatic phase and the duration of surgery and between the anhepatic phase and the need for blood replacement. The analysis of the first level of postoperative events found that the intensive care unit stay was significantly related to both the duration of surgery and the need for blood replacement. The intensive care unit stay was in turn related to the second level of postoperative events, namely the length of hospital stay. Finally, total charges were directly related to length of hospital stay. The overall 1-year actuarial patient and graft survival rates were 94% in the piggyback and 96% in the VVB groups, respectively. CONCLUSIONS: These data demonstrate that surgical choices in complex procedures such as orthotopic liver transplantation trigger a chain of events that can significantly affect resource utilization. In the current healthcare climate, examination of the sequence of events that follow a specific treatment may provide a more complete framework for choosing between treatment alternatives.     

Cavocaval adult liver transplantation and retransplantation without venovenous bypass and without portocaval shunting: a prospective feasibility study in adult liver transplantation

BACKGROUND: The original method of liver transplantation (LT) included recipient inferior vena cava (IVC) resection and the use of extracorporeal venovenous bypass (VVB). Refinements in technique permit transplantation to be done with IVC preservation and without VVB use. MATERIAL AND METHODS: Between November 1993 and November 2000, 202 consecutive grafts were performed in 188 adults (>/=16 years of age). Twelve patients (6.4%) received two and three retransplants (re-LT). Split grafting was performed 19 times (19 of 202 grafts, 9.4%). Risk factors included United Network of Organ Sharing status I (n=30, 16%), previous right upper abdominal surgery (n=32, 17.1%), caudate lobe encirclement of IVC (n=65, 32.2%), IVC (n=24, 11.9%), and splanchnic venous modification (n=58, 30.9%), transjugular intrahepatic portosystemic stent shunt (n=34, 16.8%), giant (>5 kg) liver tumor (n=6, 3%), septic necrosis of the caudate lobe (n=1, 0.5%), and previous cavocaval (n=13, 6.4%) or classical LT (n=5, 2.5%). RESULTS: IVC preservation, avoidance of IVC cross clamping and of VVB use were possible in 98.9%, 93%, and 99.5% of 183 primary LT and in 89.5%, 84.2%, and 89.5% of 19 re-LT. Temporary portocaval shunting was never applied. Perioperative mortality was 1.2%. There was no allotransfusion in 73 (36%) grafts and 45 (22%) patients were immediately extubated. Permanent hepatic vein and caval problems were encountered in three (1.5%) grafts. One patient needed stent placement to treat IVC stenosis. Actual 3- and 12-month patient survival for whole, re-LT, and right-lobe split LT groups were 94.7%, 94.1%, 94.7%, 88.2%, 94.1%, and 89%. Three-month graft survival rates for these groups were 92.6%, 94.7%, and 84.2%. CONCLUSIONS: LT with IVC preservation and without VVB use and portocaval shunting is possible in nearly all primary transplants and in the majority of re-LT.