Problematic vascular reconstruction in liver transplantation. Part I. Arterial

Arterial inflow is essential for graft function after liver transplantation. Sometimes the recipient celiac axis is not suitable for anastomosis, and in these cases a conduit from either the aorta or iliac artery is an alternative. We retrospectively reviewed 32 patients who required arterial conduits and compared them with a matched control group who underwent standard arterial reconstruction (donor celiac artery to recipient celiac artery). The indications and surgical technique for arterial conduits are presented. There were no differences in intraoperative vascular flow studies, postoperative liver function, or incidence of rejection in the two groups. There were, however, more deaths in the conduit group, two of which are related to the retropancreatic conduit technique, with the others caused by the patients' underlying condition at transplantation. There was no morbidity or death associated with the antepancreatic conduit techniques. We therefore believe the use of arterial conduits from the aorta or iliac artery, when placed antepancreatically, are safe and should be used without reservation when indicated.     

Problematic vascular reconstruction in liver transplantation. Part II. Portovenous conduits

Eight of 265 orthotopic liver transplant procedures performed at this institution since December 1984 have used venous conduits to reconstruct an occluded portal system and supply portal blood to the allograft. The factors mandating the use of these conduits were variable, and several reconstructive techniques were used. We present a series of patients with various conditions in which portal conduits were indicated and describe and illustrate the inherent technical considerations.     

A novel paper cuff for vascular reconstruction in canine liver transplantation

A new, simple method of producing optimal cuffs using thin paper and then setting it in resin for vascular reconstruction in canine liver transplantation is herein described. Thin Paper was cut into a paper tape strip. By fixing both ends of this paper tape, a cylinder paper core of any desired size could thus be obtained. The paper core was immersed into a two-liquid mixture-type resin, removed, and left to harden. The paper cuffs (0.2mm or less in thickness) were then used for anastomoses of the portal vein and the infrahepatic inferior vena cava in a series of 10 consecutive canine liver transplantations. Out of 10 animals, 8 survived for more than 5 days. The vascular patency in these 8 animals at the cuff anastomotic sites was 100% at postmortem. We therefore conclude that this paper cuff appears to be useful for various types of experimental liver transplantations in large animals.     

肝移植中血管异常时的血管重建

目的:探讨肝移植过程中血管异常时血管重建的方式和方法.方法:对16例肝移植的供肝动脉变异、受体肝动脉异常和受体门静脉血栓形成采用了多种方法进行重建,术后采用彩色多普勒超声检查的方法监测重建血管的通畅情况.结果:肝移植术后,14例重建的血管通畅良好,生存正常;1例术后7d发生门静脉血栓形成,并于术后4周死于消化道大出血;1例术后7d死于药物引起的严重的血管内溶血,但重建血管通畅良好.结论:根据各种血管异常时血管重建的原则和选择适当的血管重建方式是保证肝移植成功的关键.     

Outcome of extra-anatomic vascular reconstruction in orthotopic liver transplantation

BACKGROUND: Portal venous and hepatic arterial reconstruction are critical to successful outcomes in orthotopic liver transplantation (OLT). With portal vein thrombosis or inadequate hepatic arterial inflow, extra-anatomic vascular reconstruction is required. However, the clinical outcomes following extra-anatomic vascular reconstruction are largely unknown. METHODS: To determine the outcomes associated with extra-anatomic vascular reconstruction, we performed a retrospective review of 205 OLT recipients transplanted between 1995 and 2000. RESULTS: Extra-anatomic portal venous inflow was based upon the recipient superior mesenteric vein using donor iliac vein graft in a retrogastric position (n = 12). Extra-anatomic arterial inflow was based on recipient infrarenal aorta using donor iliac artery graft through the transverse mesocolon (n = 25). OLT with routine anatomic vascular construction served as control (n = 168). Extra-anatomic vascular reconstruction was not associated with increased morbidity, mortality, operating room time, length of stay, or thrombosis. CONCLUSION: We conclude that extra-anatomic vascular conduits are associated with excellent long-term outcomes and provide acceptable alternatives for vascular reconstruction in OLT.     

Complex vascular reconstruction using donor's vessel grafts in orthotopic liver transplantation

The vascular abnormalities of recipients are associated with reconstructive difficulties with an increased risk of postoperative complications. We performed an orthotopic liver transplantation that required a complex vascular reconstruction using donor vascular grafts. A patient with hepatitis B virus cirrhosis received a liver from a brain-dead donor. Dynamic computed tomography revealed complete obstruction of the portal vein due to thrombosis as well as narrowing of the hepatic arteries. We employed orthotopic liver transplantation using the piggy-back technique with complex reconstruction of the portal vein and the hepatic arteries. For portal vein reconstruction, we used the donor's iliac vein as an interpositional conduit from the recipient's gastric coronary vein to graft the portal vein. The hepatic arteries of the graft were reconstructed at the back-table before anastomosis to the side of superior mesenteric artery using an interpositional conduit of the donor's external iliac artery. All postoperative studies revealed good graft function with an excellent blood flow through all vascular anastomoses during the first year postoperatively.     

同种异体原位肝移植的复杂肝动脉重建经验总结

目的  总结同种异体原位肝移植术中复杂肝动脉重建的相关经验。方法  回顾性分析2015年1月至2019年3月期间行复杂肝动脉重建的7例肝移植受者资料。其中4例经典肝移植,3例背驮式肝移植。观察受者术中的一般情况,包括无肝期、术中出血量、肝动脉吻合时间、手术时间; 观察受者预后情况及并发症发生情况。结果  2例供者变异右肝动脉重建血管,分别用供者腹腔干或肝总动脉与受者肝总动脉吻合; 2例用髂动脉搭桥,然后供者肝动脉与受者腹主动脉吻合; 1例供者肠系膜上动脉与受者肝总动脉端端吻合; 1例供者腹腔干与受者脾动脉吻合; 仅1例因肝动脉吻合后出现急性肝动脉血栓,需再次行肝移植。6例肝移植受者均顺利完成手术,无围手术期死亡,无肝期49~77 min,术中出血量300~1 500 mL,肝动脉吻合时间23~56 min,手术时间5.3~11.1 h。术后住院时间23~56 d,均未出现肝动脉血栓、狭窄。所有受者术后2周内肝功能基本恢复正常,无严重外科并发症发生,移植肝均获得良好的功能。结论  正确辨别肝动脉有否变异,选择适宜的方式处理供、受者肝动脉并重建新肝动脉血供,是肝移植术中的关键步骤。     

Artificial vascular graft for inferior vena cava reconstruction in living donor liver transplantation: a case report

Artificial grafts are not recommended because of the high incidence of thrombogenic effects. However, in some situations, such as emergency or when no vascular bank is available, an artificial graft must be used. We present a case in which a polytetrafluoroethyline graft was used as a conduit to reconstruct the retrohepatic vena cava severed during living donor liver transplantation (LDLT). A 48-year-old woman had end-stage primary biliary cirrhosis for 5 years received a right lobe liver graft from her son. The retrohepatic vena cava was divided and ligated in several sequences. The upper end of the severed retrohepatic vena cava retracted into the liver parenchyma. The lower end of the severed vena cava was distended, with multiple stitches. A 16-mm artificial graft was used as a conduit to replace the inferin vena cava for outflow reconstruction. The patient tolerated the complicated procedure well. No anticoagulant was used throughout the entire course. The patient has been well with excellent liver function after follow-up for more than 5 years. Magnetic resonance imaging and Doppler ultrasonographic studies showed good patency of the cava with no evidence of thrombosis. We suggest use of an artificial graft in living donor liver transplantation, in particular in urgent situations when autologous or allogeneic vessels are not available.     

Novel magnetic rings for rapid vascular reconstruction in canine liver transplantation model

OBJECTIVE: Magnetic rings were used for rapid vascular reconstruction in a canine liver transplantation model. MATERIALS AND METHODS: Thirty-two adult mongrel dogs weighing 13 to 16 kg were randomly selected as donors or recipients of transplantations. The recipients were randomly divided into two groups: group A (n = 10) had magnetic rings used for vascular reconstruction without venovenous bypass; group B (n = 6) had vascular reconstruction performed by continuous suturing with splenojugular venovenous bypass. RESULTS: In group A, the entire operative period was 3.24 +/- 0.49 hours, the durations of clamping the portal vein and the infrahepatic vena cava of the recipient were 5.89 +/- 2.27 minutes and 3.89 +/- 0.73 minutes, respectively. In group B, the entire operative period was 4.12 +/- 0.51 hours with the duration of clamping portal vein and infrahepatic vena cava, 28.33 +/- 6.04 minutes and 12.16 +/- 3.72 minutes (P < .01 vs group A). In group A, mean arterial pressure dropped during the anhepatic phase but recovered quickly after reperfusion. The fluid infusion was about 730.56 +/- 50.56 mL in the group A and a pressor agent was unnecessary. In group B, blood pressure dropped during the anhepatic phase and slowly recovered. The fluid infusion was about 2241.67 +/- 390.78 mL and a pressor agent was used to maintain the blood pressure of the recipient. No twist or thrombus was discovered in the anastomoses group A and the endothelium at the site of anastomosis was entire. In group B, errhysis was common in the anastomotic stomas. Nine of 10 dogs in group A survived more than 3 days, the longest being 8 days, whereas four of the six dogs in group B survived less than 3 days. CONCLUSION: The results showed that the anhepatic time was significantly shortened (about 5.89 +/- 2.27 minutes) in group A compared with group B and venovenous bypass was unnecessary. Magnetic rings could be used for rapid vascular reconstruction in canine liver transplantation model. The long-term results of this procedure should be clarified before it is applied in clinical practice in the future.     

A rare case of chest wall reconstruction in a child

IntroductionEwing sarcoma/primitive neuroectodermal tumour (ES/PNET) is the most common malignant tumour of the chest wall in children and young adults. Chest wall defect left after complete resection of the involved ribs and chest wall defect requiring reconstruction, is surgically challenging for cosmetic as well as for functional purposes especially in growing children.ImportanceA rare but feasible and simple technique for a case of chest wall tumour reconstruction has been described here with its successful outcome with available composite muscular vascularised flap.     

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.     

Biliary tract reconstruction in liver transplantation

Biliary tract complications are often referred to as the Achilles' heel of liver transplantation and various techniques have been developed to overcome them. The two major methods of bile duct reconstruction currently in use consist of either (1) choledochocholedochostomy over a T-tube or, when duct-to-duct approximation is not feasible, choledochojejunostomy over an internal stent, or (2) interposition of the donor gallbladder as a conduit between the donor bile duct and either the recipient bile duct or a jejunal loop. Although these standardizations of biliary tract reconstruction have resulted in a reduction of biliary complications after liver transplantation, further advancement in the elucidation of ampullary obstruction and viability of the donor bile duct is needed.     

Complications of venous reconstruction in human orthotopic liver transplantation.

In 313 consecutive recipients of 393 orthotopic liver grafts, there were 51 (16.3%) and nine (2.9%) patients who had pre-existing portal vein and inferior vena cava abnormalities, respectively. These abnormalities required adjustments in the transplant operation and were a source of morbidity and mortality. The incidence of thrombosis of the reconstructed portal vein was 1.8%. Only three (0.8%) vena caval thromboses were seen after 393 liver replacements. Venous stenoses or disruptions were rare. Six women with the Budd-Chiari syndrome had liver replacement. Although this disorder is a veno-occlusive disease, five of the recipients achieved prolonged survival, only one had recurrence of disease, and three are alive after 2-6 years.     

Bile duct reconstruction in liver transplantation

Complications of the biliary anatomosis are common after liver transplantation. Even with improved techniques the frequency of biliary complications is approximately ten percent. Main reason for this high morbidity rate is the unfavourable blood supply to the biliary tract. A variant of reconstructions has been described and recommended. The end-to-end-choledochocholedochostomy over a T tube turned out to be the preferred technique in most centers. In cases of different diameter of donor and recipient biliary tract, the side-to-side-choledochocholedochostomy provides a relayable alternative method. When the length of the bile duct doesn't allow direct anastomosis, the gallbladder-conduit may help to overcome this problem. The choledochojejunostomy with Roux-en-Y loop has become a frequently used biliary anastomosis, especially when the recipients bile duct is absent or otherwise destroyed. - Our own experience with fourteen liver transplantations shows biliary tract complications in three cases: a leakage and a stenosis of the anastomosis after choledochocholedochostomy were successfully transformed to a hepaticojejunostomy. In the third case, intrahepatic biliary stenosis were treated by percutaneous transhepatic dilatation.     

Biliary tract reconstruction in liver transplantation

Refinements in biliary tract reconstruction and the frequent use of cholangiography have produced a marked decline in the number of deaths from biliary complications after liver transplantation. The authors' method of reconstruction differs from those of others in that it employs no stents or T tubes and retains the donor gallbladder, allowing access to the biliary tract for radiologic purposes in the post-transplant period. In a series of 161 consecutive liver transplants, the frequency of biliary complications was 13.6% (15 anastomotic and 7 gallbladder-related). Of three deaths that occurred in patients with biliary complications, one was due to the complication itself. A Roux-en-Y reconstruction with anastomosis to the donor duct was associated with the lowest anastomotic complication rate (2.2%). Upper abdominal surgery before transplantation, especially shunting, was a major risk factor for biliary complications.     

A new technique for bile duct reconstruction in liver transplantation

Biliary complications are one of the most important problems in liver transplantation. Despite various refinements of surgical technique, liver transplantation is associated with significant numbers of biliary problems. In this article, we describe our novel "intraoperative transhepatic biliary catheter insertion" technique for biliary reconstruction in 29 patients, since November 2004 comparing results before and after its implementation. 5-F Kumpe catheter is inserted into the biliary system in two steps. The first is completed at the back table, and the second during the recipient operation. The grafts were from cadavers in 10 cases, with the remaining ones from living donors. Ten patients received whole-liver grafts, 11 received a right lobe, and eight received a left-lateral lobe or left lobe. The mean weight of the living donor grafts was 598 g (range = 270 to 975 g). The mean graft weight-to-body weight ratio in the living donor liver transplantations was 1.6% +/- 1.0% (range, 0.8% to 4.1%). Intraoperative transhepatic biliary catheter insertion was performed with a duct-to-duct anastomosis in 27 cases and with a Roux-en-Y hepaticojejunostomy in two cases. The only biliary complication was one case (3.4%) of bile leakage from the anastomotic site. This rate is significantly lower than that for duct-to-duct biliary reconstructions prior to the new catheter technique (13.0%; P < .05). This new technique of biliary reconstruction with intraoperative biliary catheter insertion has significantly reduced our biliary complication rate. Transhepatic biliary stenting prevents biliary complications and makes it simple to maintain percutaneous access in case such problems arise. However, further studies are needed to compare incidence rates of biliary complications when our novel technique is used versus other surgical techniques.