Innovative technique for preventing hepatic artery kinking in living donor liver transplantation

Abstract

Hepatic artery thrombosis and bleeding are sources of morbidity and mortality after liver transplantation. Reported incidences of arterial complications have ranged from more than 6% to 12.5%.1, 2 Surgeons are usually faced with arterial kinking after liver reduction. Arterial kinking may interfere with blood flow3 or pseudoaneurysm formation4 over the anastomosis site, which can contribute to the complication. Fibrin sealants are known to accelerate wound healing and enhance implant fixation. No literature was found to support intraoperative fibrin glue application to prevent hepatic artery kinking in liver transplantation. From May to December 2012, fibrin glue–assisted hepatic artery fixation was performed routinely in all adult recipients undergoing right lobe living donor liver transplantation at our transplant center. Thirty-four patients were included in the present study. The study had received approval from our institutional review board. All patients had an arterial anastomosis between the graft's right hepatic artery (cut at the proximal level of the bifurcation without left hepatic artery involvement) and the recipient's right (or left) hepatic artery. We did not intentionally cut the artery short to achieve a good-size anastomotic patch. Each anastomosis was performed via fixed surgery with 8-0 Prolene interrupted sutures and with the aid of a microscope or surgical loupes. In our experience, the kinking site was usually located in the anastomosis area (Fig. 1A). We stretched each artery, especially at the anastomosis site, as straight as possible to prevent kinking, redundancy, or malposition, regardless of the length (Fig. 1B). A fibrin sealant (Tissucol Duo Quick; 2 mL/set) was locally sprayed with a 2-syringe application device and a pressure-controlled spray system over each side of the whole artery. A whitish membrane coated the vessel, and this resulted in hemostasis and sealing (Fig. 1C). Finally, we freed the tension and let the artery return back to its natural position. The previous kinking curve became straight, and the artery curvature was far from the anastomosis site. Thus, it did not lead to stenosis or bleeding (Fig. 1D). Beginning in May 2012, we routinely sprayed fibrin glue over the hepatic artery and stretched the vessel after the completion of the anastomosis suture and liver reduction as previously described for right lobe living donor liver transplantation. Through December 2012, 34 patients underwent the procedure. These patients were discharged smoothly, received regular follow-up, and remained free of mortality and morbidity related to hepatic artery thrombosis or bleeding. Hepatic artery kinking is a frequent condition when the liver is released in its final position during the transplantation procedure. It has been correlated with postoperative complications such as bleeding and stenosis that require surgical interventions or other invasive procedures. In the recent literature, the incidence of hepatic artery stenosis has ranged from 1.6% to 8% in adult recipients,3 and it has been presented as the most common cause of early graft loss.5 The risk of hepatic artery stenosis and thrombosis is increased by small diameter (<3 mm), atherosclerotic vessels, hypercoagulable states, anatomical variations requiring vascular reconstruction, and long arteries. The last two might be responsible for arterial kinking and the subsequent high risk of hepatic artery thrombosis.6 Arterial kinking remains a major unsolved problem, and there is no evident consensus among the different expert attending surgeons.3 Additionally, reports discussing techniques to deal with hepatic artery kinking and, therefore, prevent subsequent complications such as stenosis and bleeding are limited. The most common method is to reduce the length of the hepatic artery. However, there is the dilemma of shortening the artery to prevent kinking or lengthening the artery to approximate the anastomosis during suturing. Others have performed Surgicel or omental interposition to prevent kinking of the hepatic artery.3 However, the postoperative complications of these antikinking methods can include surgical infections and difficulties with relaparotomy due to omentum adhesion.3 No consensus is currently available regarding the most effective method for preventing arterial kinking. Because of its efficacy, tolerability, and lack of adverse effects, fibrin glue is a potentially valuable tool for tissue fixation and adherence in various surgical applications.7 Until now, there has been no study reporting the application of fibrin glue to hepatic artery fixation in living donor liver transplantation. In comparison with recent reports about antikinking procedures, the use of a fibrin sealant for hepatic artery fixation is a relatively safe and useful method that poses less risk of foreign body infection or omentum adhesion. The procedure needs an extended observational period to show its long-term effects and stability. Yu-Shu Cheng, M.D.1 Ping-Yi Lin, Ph.D.2 Kuo-Hua Lin, M.D.1 Chih-Jan Ko, M.D.1 Chia-Cheng Lin, M.D.1 Yao-Li Chen, M.D.1,3 1Department of Surgery and 2Transplant Medicine and Surgery Research Centre Changhua Christian Hospital Changhua City, Taiwan 3School of Medicine Chung Shan Medical University Taichung, Taiwan