Impact of Hepatic Arterial Reconstruction on Orthotopic Liver Transplantation in the Rat

ABSTRACT

Orthotopic liver transplantation (OLT) models in rats have been investigated in many studies, but detailed information on the impact of hepatic artery (HA) reconstruction on postoperative factors remains to be investigated. HA reconstruction also requires advanced skills. The effect of the reconstruction of the HA by a hand-suture technique in rats with a whole-liver syngeneic graft was investigated. Long-term survival, histopathological assessment, immunohistological evaluation, and blood biochemistry were investigated until postoperative day (POD) 28. From the early postoperative period, significant differences between OLTs with or without HA reconstruction were found in graft parenchymal damage, induction of apoptosis, and transaminase levels, though survival curves and the coagulation profile showed no differences. In OLT without HA reconstruction, biliary proliferation was decreased at POD 5–14, and total bilirubin level was increased at PODs 10 and 14. The study indicates that HA reconstruction is required for reliable OLT in rats.     

大鼠40％小体积肝移植肝动脉重建的意义

目的 探讨肝动脉重建在大鼠小体积肝移植中的意义.方法 采用改良二袖套法建立大鼠40%小体积肝移植模型,实验分重建动脉组和未重建动脉组,观察1周生存率,并于术后1、2、4及7 d检测肝功能、观察移植肝组织学变化以及免疫组化法检测肝细胞增殖细胞核抗原(PCNA)的表达.结果 重建动脉组1周生存率为65.0%(13/20),未重建动脉组1周生存率为50.0%(10/20),2组比较差异无统计学意义(P>0.05).2组ALT和TB于术后第1天即开始明显升高,第2天达高峰,以后逐渐降低;重建动脉组TB于第2、7天低于未重建动脉组,ALT于第2、4天低于未重建动脉组,差异均有统计学意义(P＜0.05).重建动脉组术后中央静脉及肝窦扩张程度较未重建动脉组相对较轻,可见较多二倍体和多倍体肝细胞;2组大鼠移植肝的肝细胞中PCNA表达均于术后第2天达高峰,重建动脉组术后第1天的PCNA表达阳性率高于未重建动脉组(P＜0.01),而术后第7天则低于未重建动脉组,差异有统计学意义(P＜0.05).结论 肝动脉重建可明显改善大鼠小体积移植肝的功能,促进移植肝的再生,有效地保护移植肝的组织学结构,重建动脉组术后早期肝细胞增殖较未重建动脉组活跃.     

肝动脉-腹主动脉搭桥在原位肝移植术中的应用

目的探讨供肝动脉与受体肾动脉下的腹主动脉之间用同一供体的骼动脉进行搭桥的方法及其相关并发症的影响因素。方法回顾性分析8例使用同一供体的髂动脉进行肾动脉平面以下肝动脉-腹主动脉搭桥的肝移植术临床资料。结果8例患者术中肝动脉-腹主动脉搭桥用时53～126min，术后发生胆瘘1例，胆道感染并肝内胆汁瘤形成1例，其余6例患者恢复顺利，肝功能1周左右恢复正常；无肝动脉并发症发生。结论使用供体髂血管进行肝动脉-腹主动脉搭桥，对于无法行常规肝动脉吻合的受体是一种安全、有效的方法。     

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。     

Image Findings in Celiac Artery Stenosis Due to Median Arcuate Ligament Compression

Celiac axis stenosis caused by extrinsic compression by the median arcuate ligament (MAL) is present in up to 5 % of patients undergoing pancreaticoduodenectomy. Failure to identify and manage MAL compression can lead to potentially devastating postoperative consequences that include frank liver necrosis and death. We report an incidental discovery of celiac axis stenosis by MAL in a patient prepared for pancreaticoduodenectomy. Image findings and operative management are discussed.     

原位肝移植术中动脉重建及术后并发症的防治

目的探讨原位肝移植肝动脉重建技术及其并发症的影响因素和防治。方法回顾性分析31例原位肝移植的临床资料,分析肝动脉重建及其并发症的影响因素,以及肝动脉并发症的防治。结果31例受体肝动脉均无变异。活体肝移植中供体肝动脉2例存在变异,其中1例副肝左动脉来源于胃左动脉,移植前肝左动脉、副肝左动脉成形后取供体的大隐静脉搭桥,与肝固有动脉与胃十二指肠动脉汇合处吻合;1例副肝右动脉来源于胃十二指肠动脉,行双动脉吻合。1例活体双供体肝移植行双动脉吻合;1例再次肝移植行腹主动脉搭桥;受体肝动脉直径<3mm6例,3～5mm17例,≥5mm8例。肝动脉吻合时间为23～70min,平均(31.46±9.07)min。术后32d发生肝动脉狭窄1例,行狭窄处球囊扩张后放置动脉支架,术后随访4个月肝功能及肝动脉血流良好,其余术后观察2～7个月均无肝动脉血栓形成及其他动脉并发症。结论重视引起肝动脉并发症的诸多因素,应用显微外科技术进行精细的肝动脉吻合,适当使用抗凝药物,能有效降低肝移植术后的肝动脉并发症;及时有效地处理肝动脉并发症能明显提高肝移植患者的生存率。     

Median Arcuate Ligament Syndrome in a patient with Crohn's disease

INTRODUCTIONThe Median Arcuate Ligament Syndrome is a rare condition characterized by postprandial abdominal pain, bowel function disorder and weight loss. We report the first case to our knowledge of Crohn's disease and Median Arcuate Ligament Syndrome.PRESENTATION OF CASEThe patient was a 33 year-old female with a previous diagnosis of Crohn's disease. Acute postprandial abdominal pain affected the patient every day; she was, therefore, referred to US-Doppler and magnetic resonance angiography of the abdominal vessels and received a diagnosis of Median Arcuate Ligament Syndrome. Consequently, the patient was surgically treated, releasing the vascular compression. After the operation, she reported a complete relief from postprandial pain which was one of her major concerns. Subocclusive symptoms occurred after six months due to the inflammatory reactivation of the terminal ileitis.DISCUSSIONThe diagnosis of Median Arcuate Ligament Syndrome is mainly based on the exclusion of other intestinal disorders but it should be always confirmed using noninvasive tests such as US-Doppler, angio-CT or magnetic resonance angiography.CONCLUSIONThis case demonstrates that the Median Arcuate Ligament Syndrome could be the major cause of symptoms, even in presence of other abdominal disorders.     

Relationship of Anatomic Variations and Arterial Reconstruction of the Hepatic Artery: Prevalence and Effect on Orthotopic Liver Transplantation.

BackgroundIdentifying anatomic variations of the hepatic artery is essential in liver transplantation. The artery supply is crucial for the procedure's success, and, in some cases of anatomic variations, they need reconstruction. Hepatic artery thrombosis is a severe vascular complication. This study evaluated the prevalence of anatomic variations and correlated arterial reconstructions with hepatic artery thrombosis.MethodsWe performed a retrospective analysis of medical records, adult patients undergoing liver transplant, donor's arterial anatomy, arterial reconstructions, and thrombosis after transplant from January 2019 to December 2020.ResultsAmong 226 cases, 71% had normal anatomy. All these patients met Michel's classification subtypes, of which 161 (71%) were class I, which is the most common. The second most common variation was class II, with 25 donors (11%), followed by class III, with 17 donors (7.5%). Anatomic artery variations were a risk factor for hepatic artery thrombosis development (odds ratio [OR], 7.2; 95% confidence interval [CI], 2.1-22.5; P = .002). In the same way, the artery reconstruction was associated with hepatic artery thrombosis arising with postoperative time (OR, 18.0; 95% CI, 4.9-57.5; P < .001). Global hepatic artery thrombosis occurred in 11 cases (4.87%).ConclusionAnatomic hepatic artery variations are frequent and do not make liver transplant unfeasible. However, variations that require reconstruction may raise the risk of thrombosis.     

Complications of Arterial Reconstruction in Living Donor Liver Transplantation: A Single-Center Experience

Purpose Microsurgical reconstruction of the fine hepatic arteries (HA) reduces the chance of complications in living donor liver transplantation (LDLT). We reviewed HA reconstructions and analyzed their complications and treatment in a single center. Methods Between August 1996 and September 2004, we performed LDLT on 71 adults and 19 children. Patients received a lateral segment graft (n = 16), a left lobe graft (n = 11), an extended left lobe graft (n = 12), or a right lobe graft (n = 51). Results Hepatic artery reconstruction was performed by end-to-end anastomosis under an operating microscope in all except five adults who received right lobe grafts with loupe magnification. Arterial complications developed in 5 (5.6%) of the 90 patients. Three patients required reanastomosis during their primary operation because of HA thrombosis, anastomotic kinking, and stenosis, respectively. There were three postoperative complications: an anastomotic stenosis, revised by percutaneous transluminal angioplasty; rupture of an HA pseudoaneurysm, treated by embolization; and anastomotic kinking, revised by reanastomosis. The patient with the pseudoaneurysm died of arterial complications. Multivariate analysis of cases before (4/13, 30.8%) and after 2000 (1/77, 1.3%) revealed that surgical experience was the only significant factor in reducing the incidence of HA complications (P = 0.007). Conclusion Case number-dependent anastomotic reliability using microsurgical techniques is important for safer arterial reconstruction.     

Outcome in Right Living Related Liver Transplantation with Branch-Patch Arterial Reconstruction

cRight lobe living liver transplantation is being performed worldwide with increased frequency. Difficult arterial reconstructions are often encountered because of small diameter or discrepancy between arterial stumps. The risk of arterial thrombosis is reported as high as 26%: microsurgical techniques have reduced this rate below 2%, increasing warm ischemia time. We have developed a new branch patch technique in living related liver transplantation using the donor cystic artery to create an enlarged patch anastomosis that enables increase in the vessel’s diameter and therefore greater inflow to the liver. We have followed 8 patients treated with this technique. After more than 1 year (mean follow-up: 636 days) we did not observe any arterial thrombosis by Doppler ultrasound performed every 3 months. The mean resistance index was 0.68 (0.57–0.83–). Three patients died with functional graft without signs of thrombosis. We believe that the cystic artery branch patch technique is feasible in all cases. It is fast (mean time: 6.2 min), it allows a shorter warm ischemia time, and there is no increased risk of thrombosis.     

Splenic Artery Transposition for Arterial Reconstruction in Living Donor Liver Transplantation

PurposeIn living donor liver transplantation, poor compatibility of the recipient hepatic artery remains a technical challenge. Here, we analyzed our 14 years of experience with extra-anatomic hepatic artery reconstruction.MethodsBetween July 2004 and December 2018, there were 1063 liver transplantations at our center. All patients with an extra-anatomic hepatic artery reconstruction were identified. The gastroduodenal artery and the transposed splenic artery were the primary options for extra-anatomic arterial reconstruction. Patient characteristics, operative data, and post-transplant outcome were reviewed retrospectively.ResultsThere were 22 patients with extra-anatomic hepatic artery reconstruction, 6 with gastroduodenal artery, and 16 with splenic artery. There were 2 major complications: 1 patient underwent early reoperation due to bleeding from the splenic artery trunk and another had an iatrogenic injury to the transposed splenic artery during conversion hepaticojejunostomy. Both were treated successfully with surgery. One patient died perioperatively due to sepsis. The 1- and 3-year graft survival rates of these 16 patients were 93.7% and 87.5%.ConclusionIf the hepatic arteries are not suitable for anastomosis, then we consider the gastroduodenal artery and the splenic artery to be the conduits of choice for extra-anatomic arterial reconstruction. The transposed splenic artery is very consistent, easily accessible, and offers adequate length and diameter for successful arterial anastomosis.     

肝移植术肝动脉栓塞的原因及血管重建的方式

目的　分析肝移植术中和术后肝动脉栓塞(hepaticarterythrombosis,HAT)的原因,并探讨不同血管重建方式的效果。　方法　回顾性总结Pittssburgh大学器官移植中心和南京大学附属鼓楼医院共21例肝移植术中、术后HAT,其中12例(57. 1% )施行了肝动脉重建术(hepaticarteryreconstruction,HAR)。HAR方法有直接吻合(4例)、供体肝动脉-受体腹主动脉架桥术(aortohepaticinterpositiongraft,AHIG) (6例)、髂动脉架桥术(interpositiongraft,IG) (2例)。　结果　肝动脉血流重建成功率为58. 3% (7 /12);其余5例平均3. 8(3~6)d内再次发生HAT。成人HAR成功率为62. 5% (5 /8),儿童为50. 0% (2 /4)。HAR结果与HAT发生时间、HAT原因和HAR方式无明显相关性(P>0. 05)。　结论　肝移植术HAT可能原因有机械因素、受体肝动脉细小、供体肝动脉感染、供体DIC等,尽量减少或避免上述危险因素是最好的预防方法。肝移植术HAT时HAR方式包括直接吻合、AHIG、IG等,成功取决于能否及时获得诊断。有趋势表明机械因素所致HAT,HAR方式采用直接吻合和AHIG有较好的临床结果。     

大鼠原位肝移植动物模型制作要点

目的建立稳定的大鼠原位肝移植模型。方法参照Kamada等法建立大鼠原位肝移植模型，经门静脉灌注肝脏，改进肝上下腔静脉吻合法为单线连续缝合法。结果210只大鼠原位肝移植24h存活率为91．0％(191／210)，平均无肝期17min，1周生存率为85．2％(179／210)。结论改进大鼠原位肝移植肝上下腔静脉吻合法，可缩短受体无肝期，减少手术并发症发生率，并能提高原位肝移植大鼠的生存率。     

External Biliary Fistula in Orthotopic Liver Transplantation

During orthotopic liver transplantation (OLT), various situations may occur in which biliary reconstruction is neither technically feasible nor recommended. One bridge to a delayed anastomosis can be an external biliary fistula (EBF). This procedure allows the surgeon to execute hemostatic maneuvers, such as abdominal packing; therefore, biliary reconstruction can be subsequently performed in a bloodless operative field without edematous tissues. EBF can be made by placing in the donor biliary tract a cannula that is fixed to the bile duct using 2-0 silk ties and secured outside the abdominal wall. The biliary anastomosis will be performed within 2 days after the OLT. The aim of this study was to examine the safety of EBF in terms of the incidence of biliary complications compared with a direct anastomosis. Among 1634 adult OLTs performed in 17 years in our center, 1322 were carried out with termino-terminal hepaticocholedochostomy (HC-TT); two with side-to-side hepaticocholedochostomy; 208 with hepaticojejunostomy (HJ); 31 with EBF and delayed HC-TT, and 71 with EBF and delayed HJ. Biliary complication rates in the EBF group were 24.5%, including 23.9% in the delayed HJ and 25.8% in the delayed HC-TT. Biliary complication incidence among all OLTs was 24.6% (P = NS). No complications related to the procedure were observed. Therefore, EBF is a safe technique without a higher biliary complication rate. It may be useful when a direct biliary anastomosis is dangerous.     

Renal Dysfunction After Orthotopic Liver Transplantation

Background

Identification of risk factors of acute renal failure (ARF) after orthotopic liver transplantation (OLT) may avoid the development and attenuate the impact on patient outcome. Therefore, the incidence and risk factors of ARF after OLT at Siriraj Hospital were analyzed.

Methods

The study was retrospectively analyzed from the OLT patients at the Siriraj Hospital between January 2002 and December 2009. ARF was defined as an increased in serum creatinine level more than 1.5 times within the first week postoperation compared with the preoperative level.

Results

A total of 81 liver transplant patients were analyzed. The mean age was 52.45 years (range, 22 to 71) and there were 25 women (30.86%) and 56 men (69.14%). Indications for OLT were end-stage liver cirrhosis (n = 43, 53.09%), hepatocellular carcinoma (n = 36, 44.44%), and fulminant hepatic failure (n = 2, 2.47%). Fifty-eight patients (71.60%) developed ARF, and the perioperative mortality of these was 18.97%. The univariate analysis identified the presence of preoperative coagulopathy, prolonged intraoperative hypotension, more blood loss, and postoperative hypotension as the risk factors of ARF. By the multivariate analysis, prolonged intraoperative hypotension more than 30 minutes and presence of postoperative hypotension were the independent risk factors of ARF. During the intraoperative and postoperative periods, ARF group required more blood and blood components transfusion, longer intensive care unit stay, and higher in-hospital mortality. Seven patients (12.07%) in the ARF group required postoperative renal replacement therapy. Four patients (9.52%) developed chronic renal failure, and one of them required long-term hemodialysis.

Conclusions

ARF was a common complication after OLT, which caused increased morbidity and mortality. Although some patients required dialysis, most of them recovered normal renal function. Prolonged intraoperative hypotension and presence of postoperative hypotension were the independent risk factors of ARF after OLT.