Diffuse Portomesenteric Thrombosis Research Articles

The novel surgical technique using gastroepiploic vein for restoration of portal inflow in living donor liver transplantation for patient with diffuse portomesenteric thrombosis

The novel surgical technique using gastroepiploic vein for restoration of portal inflow in living donor liver transplantation for patient with diffuse portomesenteric thrombosis

The novel surgical technique for living donor liver transplantation in patient with diffuse portomesenteric thrombosis using gastroepiploic vein for restoration of portal inflow

The novel surgical technique for living donor liver transplantation in patient with diffuse portomesenteric thrombosis using gastroepiploic vein for restoration of portal inflow

Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis: Lessons Learned for Surgical Optimization.

Background: Multivisceral transplantation entails the en-bloc transplantation of stomach, duodenum, pancreas, liver and bowel following resection of the native organs. Diffuse portomesenteric thrombosis, defined as the complete occlusion of the portal system, can lead to life-threatening gastrointestinal bleeding, malnutrition and can be associated with liver and intestinal failure. Multivisceral transplantation is the only procedure that offers a definitive solution by completely replacing the portal system. However, this procedure is technically challenging in this setting. The aim of this study is to describe our experience, highlight the challenges and propose technical solutions.Materials and Methods: We performed a retrospective analysis of our cohort undergoing multivisceral transplantation for diffuse portomesenteric thrombosis at our institution from 2000 to 2020. Donor and recipient demographics and surgical strategies were reviewed in detail and posttransplant complications and survival were analyzed.Results: Five patients underwent MVTx. Median age was 47 years (23–62). All had diffuse portomesenteric thrombosis with life-threatening variceal bleeding. Major blood loss during exenteration was avoided by combining two techniques: embolization of the native organs followed by a novel, staged extraction. This prevented major perioperative blood loss [median intra-operative transfusion of 3 packed red blood cell units (0–5)]. Median CIT was 330 min (316–416). There was no perioperative death. One patient died due to invasive aspergillosis. Four others are alive and well with a median follow-up of 4.1 years (0.3–5.9).Conclusions: Multivisceral transplantation should be considered in patients with diffuse portomesenteric thrombosis that cannot be treated by any other means. We propose a standardized surgical approach to limit the operative risk and improve the outcome.

P2B.15: Preoperative Arterial embolization for Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis: Performance and Outcome Analysis

P2B.15: Preoperative Arterial embolization for Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis: Performance and Outcome Analysis

Diffuse Portomesenteric Thrombosis and Non-Cirrhotic Portal Hypertension Secondary to Antiphospholipid Syndrome: A Case Report

Portal vein thrombosis (PVT) may occur in the presence or absence of underlying liver disease and may lead to significant portal hypertensive complications. We present a challenging case of a patient with underlying antiphospholipid antibody syndrome (APS) who developed diffuse venous portomesenteric thrombosis and non-cirrhotic portal hypertension. A 33-year-old male with history of spontaneous PVT eight years prior, multiple DVTs and IVC filter placement, all in the context of APS, was hospitalized for a pulmonary embolism and placed on apixaban. He had not been on prolonged anticoagulation prior to this hospitalization for unclear reasons. One month later he was re-hospitalized for an esophageal variceal bleed which responded to band ligation, followed by a gastric variceal bleed for which transjugular portosystemic shunt (TIPS) was attempted and failed. A balloon occluded retrograde transvenous obliteration (BRTO) was performed and was successful. Imaging at that time was suggestive of cirrhosis although cause was unknown. He was admitted to our facility weeks later with new onset ascites and fluid demonstrating spontaneous bacterial peritonitis and suggestive of portal hypertension. Cross sectional imaging demonstrated a cavernous transformation of the portal vein (Figure 1), and patent hepatic veins. Liver biopsy showed benign parenchyma, no fibrosis, and no evidence of nodular regenerative hyperplasia (NRH). An echocardiogram showed no right heart strain or pulmonary hypertension. Mesenteric arteriogram and splenic venogram via trans-splenic access all revealed extensive thrombosis of the portomesenteric venous system including superior mesenteric vein with no vascular targets amenable to portosystemic shunting (Figure 2 and 3). Given the lack of shunt options and ongoing ascites and GI bleed risk, liver/intestine transplant was proposed. APS, among other hypercoagulable states, is associated with an increased risk of PVT as well as non-cirrhotic portal hypertension. The role of anticoagulation in non-cirrhotic patients with chronic PVT is not well studied, and while anticoagulation may prevent recurrence or progression of thrombosis, the risk of gastrointestinal bleeding is unclear. Our case demonstrates the risk of not anticoagulating patients with a high-risk condition. We emphasize the need for timely diagnosis and intervention in order to avoid devastating consequences.2369_A Figure 1. Coronal T1 fat suppressed post contrast images of the abdomen. Non-visualization of native portal vessels with cavernous transformation.2369_B Figure 2. Venogram from superior mesenteric vein collateral with no native portal vessels seen.2369_C Figure 3. Delayed portovenogram (delayed phase of SMA angiogram) with innumerable small tortuous collaterals consistent with cavernous transformation.

Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis

Introduction Multivisceral transplantation (MVTx) entails the en-bloc transplantation of almost the entire abdominal contents including stomach, duodenum, pancreas, liver and small bowel. For adults, indications for MVTx include slow growing abdominal tumors involving the mesenteric vessels, massive abdominal losses due to trauma or ischemic disease and diffuse portomesenteric thrombosis (DPMT). In the latter, DPMT will often lead to life-threatening upper GI bleeding. Furthermore, these patients often have an underlying liver cirrhosis requiring a liver transplantation. In these cases, portal revascularization is technically impossible without simultaneous replacement of the entire portal system. Aim To study the results of multivisceral transplantation for diffuse portomesenteric thrombosis. Methods A retrospective analysis from prospectively maintained database ITx patients transplanted from2000-2017 was performed and the MVTx patients were identified. Demographics, indication, donor characteristics, rejection episodes and survival were recorded. Results 4 male patients underwent MVTx in this period out of a total of 19 ITx performed at our center(21%). Median age at time of transplantation was 45 (range: 23-47). The indication for MVTx was DMPT with recurrent life treating bleeding.Underlying causes where antiphospholipid syndrome, alcoholic cirrhosis, pancreatic neuroendocrine tumor and unknown in one patient. One patient had underlying liver failure and was hospitalized at time of transplantation. Median MELD score at time of transplantation was 13 (10-32). All patients received grafts from brain-dead donors (median age: 24.5 years). To reduce massive bleeding during exenteration, embolization of the superior mesenteric artery and the celiac trunk was performed to reduce perioperative bleeding, followed by en-bloc resection of native stomach, duodenum, pancreas, liver and bowel, and finally en-bloc transplantation of the corresponding organs. GI continuity was restored by oesophagogastrostomy proximally and ileo-colostomy distally. All patients received a protective double loop ileostomy for endoscopic surveillance. Patients received basiliximab induction followed by triple maintance therapy: tacrolimus, azathioprine and corticosteroids. There were 4 rejection episodes in 3 patients, 3 of which were treatable by increasing standard immunosuppression. One patient died 254 days after surgery due to invasive aspergillosis after a severe rejection. The 3 remaining patients are alive and are nutritionally independent (median follow-up 2.14 years). Conclusions MVTx allows for complete treatment of diffuse portomesenteric thrombosis with good quality of life in patients who would otherwise die from severe bleeding. Coordination amongst the donor, embolization and implantation teams is crucial to keep blood loss and cold ischemia times as short as possible.

Intestinal Transplantation is Cost Effective in the Treatment of Complicated Intestinal Failure

Introduction: When life-threatening complications occur due to home parenteral nutrition (HPN), intestinal transplantation (ITx) is indicated. ITx is the most expensive solid organ transplant but the true cost effectiveness is unknown. Aim: To compare the costs of complicated HPN before ITx to the costs after ITx at our institution. Methods: We performed a retrospective analysis of our cohort of ITx patients, transplanted between 1/1/2000 and 31/12/2015. Total costs analyzed included all costs for surgery, admissions, diagnostics, treatments, outpatient clinics and medication. For those patients followed at our center pre-ITx, the costs before ITx, including the HPN care were included up to 2 years before surgery. All costs for pre-transplant screening were excluded from the pre-transplant data. Results: 16 patients (12 adults (7 females, mean age 43 years (23–57)) and 4 children (1 female, mean age 8 years (range: 3–17))), were included in this study. 15 patients underwent ITx while 1 patient was listed for ITx at time of analysis. 8 patients were followed at our center pre-ITx and financial data were therefore available. The causes of intestinal failure for the adults were short bowel syndrome (SBS) (67%), diffuse portomesenteric thrombosis (25%) and chronic intestinal pseudo-obstruction (8%). 2 children had SBS after volvulus and 2 children had congenital mucosal diseases. All patients were listed for ITx due to severe complications from HPN or the underlying disease. 7 patients underwent isolated ITx, 5 had a combined Liver-ITx and 3 underwent multivisceral transplantation. The 5-year patient survival was 86.7%. The median costs in year −2 (day 720 – 366 pre-ITx) was € 90 891 (60 682–342 299) and year – 1 (day 365–1 pre-ITx) was € 134 006 (83 854 - € 275 712). After ITx, the costs of the first year were € 185 662 (122 483–571 301). In year 2, there was a 76% reduction in overall costs to € 44 893 (3 905–293 985) due to a reduction of hospitalizations. In year 1, the patients were hospitalized for a median of 145 days (78–365) while in year 2, this had dropped to 37 days (0–319). In adult patients, the costs drop much faster while remaining quite high until year 3 in children.FigureConclusion: Intestinal transplantation, while being an expensive procedure, was cost effective in adults by the second year. In children, ITx was cost effective from the third year onward, because of more complicated treatment of underlying congenital disease.

Intestinal Transplantation is Less Expensive Compared to Long-Term Home Parenteral Nutrition in Adults.

Introduction: The primary treatment of intestinal failure is home parenteral nutrition (HPN) while intestinal transplantation (ITx) is reserved for those cases where severe complications occur. In renal failure, transplantation has been promoted over dialysis because transplantation reduces the costs. It is unknown whether ITx is cost effective in the treatment of chronic intestinal failure. Aim: To compare the costs of uncomplicated HPN patients to a cohort of ITx patients at our institution. Methods: First, we collected the cost data from our adult cohort of stable, long-term (>2 years) HPN patients. We included all patients with minimum of 5 years follow-up. The first two years after start of HPN were excluded in order to identify the actual cost of stable intestinal failure patients. Second, we analyzed our cohort of ITx patients, transplanted between 1/1/2000 and 31/12/2015. We collected all costs from day 1 until 5 years post-transplant. Next, we compared the costs between stable HPN patients and ITx in these 5 years-period. All costs were rounded to the nearest euro and corrected for inflation to 2015. Results: There were 28 HPN patients in this cohort, (14 females, mean age 58.6 years). Median duration of HPN was 8.6 years (5.1-12.0). HPN was administered 4.1 days per week (range: 1.5-7) at 5767 total kcal (2385-10890). Indications were short bowel syndrome (SBS) (57%), intestinal dysmotility (24%), mechanical obstructions (14%) and mucosal disease (5%). There were 12 patients transplanted in this study period. The main causes of intestinal failure were SBS (67%) and diffuse portomesenteric thrombosis (20%). Indication for ITx were life-threatening complications from HPN or underlying disease. The 5-year patient survival was 83.3%. For HPN patients, the total annual costs remained quite stable at a median of € 59 524 (58 731-65 807). HPN costs (basic costs and treatment of complications) accounted for 76% of these costs. After ITx, the first year costs were € 172 133 (122 483-351 407) which then drops to € 8 832 (3 270-38 723) in year 5 (Figure 1).FigureConclusions: ITx has a high initial cost compared to stable, adult HPN patients. From year 2 onwards, ITx patients cost less than stable HPN patients. By year 4, the additional costs incurred in year 1 of ITx are recovered making the procedure cost effective.

Multivisceral transplantation for diffuse splanchnic venous thrombosis.

The development of diffuse splanchnic venous thrombosis continues to be a challenging undertaking for patients waiting for liver transplantation, requiring the utilization of highly complex surgical techniques. The aim of this article is to review the status of multivisceral transplantation (MVT) in the setting of diffuse portomesenteric thrombosis. Even though many anatomical reconstructions of the venous system have been proposed to revascularize the transplanted liver, there are only few articles describing the use of these techniques. Here we describe a succinct review of these alternatives with emphasis on MVT. MVT is a complex procedure; however, it is the only one capable of reestablishing the venous anatomy and physiology of the abdominal cavity, resolving completely the effects of portal hypertension and the baseline disease.

Emergent nonconventional mesosystemic shunt for diffuse portomesenteric thrombosis: Sparing patients from liver/multivisceral transplantation

Emergent nonconventional mesosystemic shunt for diffuse portomesenteric thrombosis: Sparing patients from liver/multivisceral transplantation

Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis

To evaluate the clinical outcomes of multivisceral transplantation (MVT) in the setting of diffuse thrombosis of the portomesenteric venous system. Liver transplantation (LT) in the face of cirrhosis and diffuse portomesenteric thrombosis (PMT) is controversial and contraindicated in many transplant centers. LT using alternative techniques such as portocaval hemitransposition fails to eliminate complications of portal hypertension. MVT replaces the liver and the thrombosed portomesenteric system. A database of intestinal transplant patients was maintained with prospective analysis of outcomes. The diagnosis of diffuse PMT was established with dual-phase abdominal computed tomography or magnetic resonance imaging with venous reconstruction. Twenty-five patients with grade IV PMT received 25 MVT. Eleven patients underwent simultaneous cadaveric kidney transplantation. Biopsy-proven acute cellular rejection was noted in 5 recipients, which was treated successfully. With a median follow-up of 2.8 years, patient and graft survival were 80%, 72%, and 72% at 1, 3, and 5 years, respectively. To date, all survivors have good graft function without any signs of residual/recurrent features of portal hypertension. MVT can be considered as an option for the treatment of patients with diffuse PMT. MVT is the only procedure that completely reverses portal hypertension and addresses the primary disease while achieving superior survival results in comparison to the alternative options.

Re-Visiting Surgical Options for Diffuse Porto-Mesenteric Thrombosis in the Era of Multi-Visceral Transplantation – A Case for Aggressive Conservatism

Re-Visiting Surgical Options for Diffuse Porto-Mesenteric Thrombosis in the Era of Multi-Visceral Transplantation – A Case for Aggressive Conservatism

Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis in a Patient with Life-Threatening Esophagogastroduodenal Bleeding

Portal vein thrombosis is the most common cause of portal hypertension in noncirrhotic patients. Variceal bleeding is difficult to treat in these patients, especially those with prehepatic diffuse portal mesenteric thrombosis. In a patient with refractory esophagogastroduodenal variceal bleeding as a result of diffuse portomesenteric thrombosis and portal hypertension, life-threatening bleeding was unresponsive to endoscopic therapy and other surgical procedures. A multivisceral transplant was performed. It was curative and also lifesaving. There is only one report in the literature mentioning multivisceral transplantation for a patient with life-threatening esophagogastroduodenal bleeding; however that patient had protein C deficiency. Our patient had normal liver and intestinal function tests and no signs of hypercoagulable disease. We believe that multivisceral transplantation should be considered as a treatment option for patients with diffuse mesenteric thrombosis, even in the absence of liver and intestinal failure, when other treatment options for variceal bleeding have failed, particularly in a younger patient with a relatively good nutritional status before transplantation.

Liver Transplant With Portocaval Hemitransposition: Blood Supply With Only Hepatic Artery Is Possible?

We present herein a case of orthotopic liver transplantation (OLT) with portocaval hemitransposition. The patient underwent OLT for hepatocellular carcinoma with diffused portomesenteric vein thrombosis. The unique feature of this case was that 6 months after the operation, because of recurrent carcinoma, the hepatic vein was occluded and the portal vein became the drainage vein and the hepatic artery was the only vessel that supplied the liver. Yet the patient survived. Regarding the unique hemodynamic changes of the patient, could we let the portal vein alone in case of diffuse portomesenteric thrombosis in OLT?