Left Lateral Section Research Articles

Laparoscopic Approach in Liver Harvesting from Living Donors for Transplantation in Children

Aim . To analyze own experience of laparoscopic liver resection in living donors and to compare our results with the experience of world leading centers. Material and Methods. In our center 32 laparoscopic liver resections for transplantation to pediatric patients have been performed since May 2016 to October 2017. Left lateral sector resection was performed in 31 cases, left-sided hemihepatectomy – in one case. Results. Mean age of donors was 28.61 (±5.84) years, mean intraoperative blood loss – 93.87 (± 50) ml, time of surgery – 276 (±44) min, length of hospital-stay – 4 (± 1.12) days. There were no complications Clavien–Dindo grade II and over. Conclusion. Laparoscopic liver resection in adult donors for transplantation to pediatric patients is followed by qualitative graft and facilitates rapid rehabilitation of living donor.

COMPREHENSIVE TREATMENT OF LARGE LIVER METASTASIS OF COLORECTAL CANCER WITH INVOLVEMENT OF THREE HEPATIC VEINS

The article presents clinical case of successful treatment of patients with metachronous, resectable liver metastasis of colorectal cancer located in hepatic veins confluence. It is shown the results of consecutive chemotherapy and portal vein embolization which reduced metastasis size and increased the volume of the left liver lateral sector. Readiness for transplantation has allowed to perform radical R0-resection. We obtained satisfactory long-term outcomes.

Ex vivo reduction of thickness in the left lateral section to tailor the graft size in infantile split deceased donor liver transplantation

Ex vivo reduction of thickness in the left lateral section to tailor the graft size in infantile split deceased donor liver transplantation

Hepatic Hemodynamics and Portal Flow Modulation: The A2ALL Experience.

A principal aim of the Adult-to-Adult Living Donor Liver Transplantation Cohort Study was to study hepatic blood flow and effect of portal flow modulation on graft outcomes in the setting of increasing use of smaller and left lobe grafts. Recipients of 274 living donor liver transplant were enrolled in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study, including 233 (85.0%) right lobes, 40 (14.6%) left lobes, and 1 (0.5%) left lateral section. Hepatic hemodynamics were recorded after reperfusion. A total of 57 portal flow modulations were performed on 52 subjects. Modulation lowered portal pressure in 68% of subjects with inconsistent effects on hepatic arterial and portal flow. A higher rate of graft dysfunction was observed in modulated vs. unmodulated subjects (31% vs. 18%; P = 0.03); however, graft survival in modulated subjects was not different from unmodulated subjects at 3 years. These results suggest the need for a study using a prespecified portal flow modulation protocol with defined indications to better define the effects of these interventions.

Laparoscopic right hepatectomy for living donation

Living donor liver transplantation has become a widely accepted alternative to cadaveric transplantation. The laparoscopic approach has demonstrated its safety and reproducibility for the left lateral section harvesting in the last decade, but remains controversial for right liver harvesting due to concerns about donor and graft safety. The selection of an eligible donor means the evaluation of, in one hand, the technical feasibility, and in the other hand, the operative risk for the donor. Such issues imply an extensive workup procedure. The operation is divided in three main steps: right pedicle dissection, parenchymal transection including bile duct division, and graft extraction. To enhance donor safety, these steps are performed in rotation between two senior surgeons in our team. Conversion criteria and technical aspects are precisely defined preoperatively to enhance donor safety.

Laparoscopic right hepatectomy for living donation

Living donor liver transplantation has become a widely accepted alternative to cadaveric transplantation. The laparoscopic approach has demonstrated its safety and reproducibility for the left lateral section harvesting in the last decade, but remains controversial for right liver harvesting due to concerns about donor and graft safety. The selection of an eligible donor means the evaluation of, in one hand, the technical feasibility, and in the other hand, the operative risk for the donor. Such issues imply an extensive workup procedure. The operation is divided in three main steps: right pedicle dissection, parenchymal transection including bile duct division, and graft extraction. To enhance donor safety, these steps are performed in rotation between two senior surgeons in our team. Conversion criteria and technical aspects are precisely defined preoperatively to enhance donor safety.

Correction of extrahepatic portal hypertension in pediatric patient after liver transplantation

Introduction. Liver transplantation is a multi-component and complex type of operative treatment. Patients undergoing such a treatment sometimes are getting various complications. One of these complications is a portal hypertension associated with portal vein stenosis.Materials and methods. In 6 years after the left lateral section transplantation from living donor in a pediatric patient the signs of portal hypertension were observed. Stenosis of the portal vein was revealed. Due to this fact percutaneous transhepatic correction of portal vein stenosis was performed.Results. As a result of the correction of portal blood flow in the patient a positive trend was noted. According to the laboratory and instrumental methods of examination the graft had a normal function, portal blood flow was adequate. In order to control the stent patency Doppler ultrasound and MSCT of the abdominal cavity with intravenous bolus contrasting were performed. Due to these examinations the stent function was good, the rate of blood flow in the portal vein due to Doppler data has reached 80 cm/sec, and a decrease of the spleen size was noted.Conclusion. Diagnosis and timely detection of portal vein stenosis in patients after liver transplantation are very important for the preservation of graft function and for the prevention of portal hypertension. In order to do that, ultrasound Doppler fluorimetry examination needs to be performed to each patient after liver transplantation. In cases of violation of the blood flow in the portal vein CT angiography performance is needed. Percutaneous transhepatic stenting of portal vein is a minimally invasive and highly effective method of correction of portal hypertension. Antiplatelet therapy and platelet aggregation control are the prerequisites for successful stent function.

LAPAROSCOPIC LEFT LATERAL SECTIONECTOMY IN LIVING LIVER DONOR

Introduction.Living donor liver transplantation has proved to be an effective, safe and radical treatment modality for patients with end-stage liver diseases. Left lateral section (LLS) of donor’s liver is used in pediatric recipients. Laparoscopic LLS procurement was fi rst described by D. Cherqui in 2002. At present, this technique is routinely used only by 5 hospitals in the world. However, up to date, some authors consider it to be a new standard to perform such a surgery in living donors.Aim.To analyze the fi rst Russian experience in laparoscopic left lateral sectionectomy (LapLLS) in living related donor.Materials and methods.From May to September 2016 fi ve LapLLS were performed in living donors. In all cases donors were women (mothers in 4 cases and aunt in 1 case). Recipients were children aged from 6 months through 3 years with body mass from 5.6 to 12.5 kg. Liver transection was carried out under conditions of maintained blood supply. Parenchymal transection was performed using a harmonic scalpel, bipolar coagulation and ultrasound dissection.Results. Average donor age was 32 ± 5 years. Average operation time was 287 ± 16 min. Average LLS graft weight was 220 ± 16 g. Intraoperative blood loss did not exceed 100 ml (95 ± 5 ml). Donors were discharged on the 3rd–4th post-op day. There were no postoperative complications in donors. Recipients were also characterized by a standard course of the postoperative period.Conclusion.LapLLS is an effective and safe method with several advantages. Primarily, these are early rehabilitation of the donors and shortening of the hospital stay, which are important for the quick return to normal way of live. Excellent visualization of anatomical structures, including vascular and biliary ones, allows performing precise selection. In addition, good cosmetic effect is also an important aspect.

THE TECHNOLOGY OF LAPAROSCOPIC DONOR EXPLANTATION OF LEFT LATERAL LIVER SEGMENT FOR TANSPLANTATION

Objective. To evaluate technical and morphological aspects of laparoscopic left lateral liver segment explantation for transplantation. Material and Methods. In Privolzhsky Federal Medical Center of FMBA of Russia 3 series (14 interventions) of laparoscopic left lateral liver sector resection were performed. Operations were performed in compliance with the principles of donor liver resection. In each series different variants of tools and hardware systems were applied. Indications were benign neoplasms of II-III segments including focal nodular hyperplasia in 12 cases and hemangioma in 2 cases. Severity of liver parenchyma damage was assessed in excised specimen. Results. Postoperative complications were not observed, patients were discharged in terms from 3 to 6 days. The average hospital stay was 3.8 days. Morphological study of histological preparations of liver tissue revealed different severity of cholestasis and steatohepatosis, fibrosis, mixed inflammatory infiltration (lymphocytes, polymorphonuclear leukocytes). Identified changes were chronic. Signs of acute ischemic damage of liver parenhima were not found. Conclusion. Laparoscopic liver resection (left lateral sector) for subsequent transplantation is technically feasible with the accumulation of experience of laparoscopic procedures.

The Romanian National Program for Liver Transplantation - 852 Procedures in 815 Patients over 17 Years (2000-2017): A Continuous Evolution to Success.

Background: Liver transplantation (LT) has become an established treatment for end-stage liver disease, with more than 20.000 procedures yearly worldwide. The aim of this study was to analyze the results of Romanian National Program of LT. Methods: Between April 2000 and April 2017, 817 pts received 852 LTs in Romania. Male/female ratio was 487/330, while adult/pediatric ratio was 753/64, with a mean age of 46 years (median 50 yrs; range 7 months - 68 yrs). Main LT indications were HBV cirrhosis (230 pts; 28.2%), HCC (173 pts; 21.2%), and HCV cirrhosis (137 pts; 16.8%). Waiting time and indications for LT, patient and donor demographics, graft features, surgical procedures, and short and long-term outcomes were analyzed. Results: DDLT was performed in 682 pts (83.9%): whole LT in 662 pts (81%), split LT in 16 pts (2.3%), reduced LT in 2 pts (0.2%), and domino LT in 1 pts (0.1%). LDLT was performed in 135 pts (16.5%): right hemiliver in 93 pts (11.4%), left lateral section in 28 pts (3.4%), left hemiliver in 8 pts (1%), left hemiliver with segment 1 in 4 pts (0.5%), and dual graft LDLT in 2 pts (0.2%). Overall major morbidity rate was 31.4% (268 pts), while perioperative mortality was 7.9% (65 pts). Retransplantation rate was 4.3% (35 pts): 27 whole LTs, 3 reduced LTs, 3 split LTs, and 2 LDLT. Long-term overall 1-, 3-, and 5-year estimated survival rates for patients were 87.9%, 81.5%, and 79.1%, respectively. One-, 3-, and 5-year overall mortality on waiting list also decreased significantly over time from 31.4%, 54.1% and 63.5%, to 4.4%, 13.9% and 23.6%, respectively. Conclusions: The Romanian National program for liver transplantation addresses all causes of acute and chronic liver failure or liver tumors in adults and children, using all surgical techniques, with good long-term outcome. The program constantly evolved over time, leading to decreased mortality rate on the waiting list.

Outflow Reconstruction Using Cryopreserved Homologous Venous Grafts in Living Donor Liver Transplantation

ObjectivesThe techniques and outcomes of outflow reconstruction in living donor liver transplantation (LDLT) using cryopreserved homologous veins at the University of Tokyo Hospital are presented. MethodsWe performed 540 LDLTs from January 1996 to March 2015. Graft types included right liver graft (n = 262), left liver graft (n = 196), left lateral sector graft (n = 53), and posterior sector graft (n = 28). We routinely use cryopreserved homologous vein grafts for the hepatic vein reconstructions to secure the large outflow of the graft. In addition to the presentation of our techniques, the cases with symptomatic outflow obstruction and the treatments were also investigated. ResultsThe 1-, 3-, and 5-year graft survival rates were 90.6%, 86.1%, and 83.5%, respectively. The incidence of severe complications (Clavien-Dindo grade IIIb and more) was 38%. The overall incidence of outflow obstruction requiring invasive treatment was 1.9% (10/540), including 3 left liver grafts (1.5%, 3/196) and 7 right liver grafts (2.7%, 7/262). Regarding the patency of the reconstructed veins, the left hepatic vein, middle hepatic vein, and right hepatic vein achieved nearly 100% patency. On the contrary, venous tributaries such as V5, V8, and inferior right hepatic vein were frequently occluded in the postoperative course. ConclusionsOutflow reconstruction is a key for the successful LDLT. Cryopreserved homologous vein graft is useful for the promising hepatic vein reconstruction.

Computerized tomography–based anatomic description of the porcine liver

BackgroundThe knowledge of the anatomic features is imperative for successful modeling of the different surgical situations. This study aims to describe the anatomic features of the porcine using computerized tomography (CT) scan. MethodsThirty large, white, female pigs were included in this study. The CT image acquisition was performed in four-phase contrast study. Subsequently, analysis of the images was performed using syngo.via software (Siemens) to subtract mainly the hepatic artery and its branches. Analysis of the portal and hepatic veins division pattern was performed using the Myrian XP-Liver 1.14.1 software (Intrasense). ResultsThe mean total liver volume was 915 ± 159 mL. The largest sector in the liver was the right medial one representing around 28 ± 5.7% of the total liver volume. Next in order is the right lateral sector constituting around 24 ± 5%. Its volume is very close to the volume of the left medial sector, which represents around 22 ± 4.7% of the total liver volume. The caudate lobe represents around 8 ± 2% of the total liver volume.The portal vein did not show distinct right and left divisions rather than consecutive branches that come off the main trunk. The hepatic artery frequently trifurcates into left trunk that gives off the right gastric artery and the artery to the left lateral sector, the middle hepatic artery that supplies both the right and the left medial sectors and the right hepatic artery trunk that divides to give anterior branch to the right lateral lobe, branch to the right medial lobe, and at least a branch to the caudate lobe. Frequently, there is a posterior branch that crosses behind the portal vein to the right lateral lobe. The suprahepatic veins join the inferior vena cava in three distinct openings. There are communications between the suprahepatic veins that drain the adjacent sectors. The vein from the right lateral and the right medial sectors drains into a common trunk. The vein from the left lateral and from the left medial sectors drains into a common trunk. A separate opening is usually encountered draining the right medial sector. The caudate lobe drains separately into inferior vena cava caudal to the other veins. ConclusionsKnowledge of the anatomic features of the porcine liver is crucial to the performance of a successful surgical procedure. We herein describe the CT-depicted anatomic features of the porcine liver.

Technical note en ALPPS fer a patient with advanced hepatocellular carcinoma associated with invasion of the inferior vena cava

Patients with hepatocellular carcinoma have a very short life expectancy if they receive no surgical intervention. A relatively new surgical technique termed “Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy” (ALPPS) has been employed for inducing rapid hypertrophy of the future liver remnant for patients waiting for hepatectomy. As portal vein embolization may not result in satisfactory hypertrophy before tumor progression occurs, ALPPS can be an alternative for patients with advanced hepatocellular carcinoma. Herein we describe an ALPPS procedure with tumor thrombectomy for a patient who had a small left liver lobe and a large hepatocellular carcinoma involving the whole right liver lobe and the middle hepatic vein and extending into the inferior vena cava. In the first-stage operation, the right portal vein was controlled and divided with a Hemolock. The right hepatic artery was well protected. Hepatic transection was performed with a 1-cm margin from the tumor. The middle hepatic vein trunk was preserved. Ten days afterwards, there was significant hypertrophy of the left lateral section of the liver, and the second-stage operation was conducted. Extended right hepatectomy and tumor thrombectomy were performed under sternotomy and total vascular exclusion. The patient had good recovery and was free of disease 10 months after the operation. ALPPS may be a good treatment option even for patients with advanced disease if carried out at high-volume centers.

Two-stage liver transplantation using auxiliary laparoscopically harvested grafts in adults: Emphasizing the concept of “hypersmall graft nursing”

Living donor liver transplantation is limited by the donor's risk in case of right liver donation and by the risk of small-for-size syndrome on the recipient in case of left lobe transplantation. This study aimed at evaluating the feasibility and results of two-stage liver transplantation using auxiliary hyper small grafts harvested laparoscopically and discussing relevant technical insights and issues that still need to be overcome. Retrospective analysis involving two patients operated at a tertiary referral center. The recipients underwent left lateral sectionectomy and then auxillary liver transplantation using laparoscopically harvested left lateral section. The native right liver was transiently left in place to sustain the initially small functional graft functional during its hypertrophy. No donor experienced postoperative complication. After 7days, the hypertrophy rate was 112% (105-120). Doppler assessments during the first two postoperative weeks showed progressive portal vein inflow decrease in the right native livers and portal vein inflow increase in the grafts. Liver biopsies on postoperative day 7 showed no lesion of overperfusion. No recipient experienced liver failure or small-for-size syndrome. Second stage hepatectomy of the native liver was undertaken in one patient. In the other patient, biliary stenosis on postoperative day 30 precluded second stage hepatectomy. This patient required retransplantation after one year. The current strategy increases donor safety and may allow increasing the pool of available grafts. Refinements in the management of the native right liver are however required to improve the feasibility rate of this strategy.

Living Donor Liver Transplantation for Biliary Atresia With Severe Preduodenal Portal Vein Stricture: Success and Pitfall of Portal Vein Reconstruction

BackgroundWe report a rare case of 10-month-old female who underwent living donor liver transplantation (LDLT) for syndromic biliary atresia with preduodenal portal vein (PV) and its severe stricture owing to the previous Kasai portoenterostomy. Because we successfully performed “left at right liver transplantation (LAR-LT) and graft rerotation” in this case, we are present tips and pitfalls for this operation. MethodsPreoperative computed tomography scan showed that her preduodenal PV was stenotic from the confluence of the superior mesenteric vein and splenic vein to hepatic hilum, which made us consider the necessity of ≥3 cm interposition vein graft to complete a safe PV anastomosis. To reduce a gap between donor and recipient's PV, we decided to put a left lateral section graft at the right subphrenic space called left-at-right liver transplantation. Thus, LDLT was performed with an identical lateral sectional graft from her father. After total hepatectomy, we implanted a graft in her right subphrenic space, and anastomosed the donor left hepatic vein to her inferior vena cava. Then, we anastomosed an interposition graft harvested from her left internal carotid vein to her PV. ResultsEven after reflowing PV flow, because the duodenum compressed the interposition vein graft, PV flows were totally insufficient. Therefore, we flipped a liver graft 180° from right to left upper abdominal cavity, which could reduce the gap between PVs and acceptable PV flow was obtained. ConclusionsIn the present case, LAR-LT could reduce the distance of PVs. In addition, our rerotation method could be useful to alleviate tension on the PV anastomosis caused by preduodenal PV.

Classification of Donor's Hepatic Veins and Venous Outflow Reconstruction at Liver Left Lateral Section Transplantation

Aims: To create anatomy-based strategy of HV reconstruction in LLS living donor liver transplantation (LDLT) Methods: Venous anatomy and clinical data of 53 pediatric recipients and their related living donors where evaluated. Recipient aged from 6 to 36 month with end stage liver decease underwent LDLT from 2004 to 2014 were included. Results: We divide all LHV and MHV variants into 4 groups: Type A - normal anatomy with common LHV trunk, longer 5 mm; Type B - common LHV trunk, less then 5 mm length; Type C - separate inflow of Sg 2 and 3 HV with distance between them less then 5 mm; Type D - separate inflow of Sg 2 and 3 HV with distance between them more then 5 mm. Type A anatomy is acceptable for standard HV plastic due to presence of enough length common graft HV trunk, for type B, C and D we purpose non-standard HV reconstruction methods. From 53 donors 37(69,8%) had normal type A anatomy, 5 (9,4%) had type B, 5 (9,4%) had type C and 6 (11,3%) had type D anatomy. Thus in 69,8% transplantations standard HV plastic was made. For other 30,1% we used one of HV reconstruction methods: 1) Circular plastic of common Sg 2-3 hepatic veins orifice by autovenouse patch from recipient portal vein confluence, which was performed in 5 cases with type B anatomy; 2) Forming of common Sg 2-3 graft hepatic veins orifice from separate Sg 2 and Sg 3 veins. Used in 5 cases with type C anatomy; 3) Harvesting of left lateral section graft with common orifice of donor left and middle hepatic veins. Performed in 6 cases with type D anatomy. Conclusions: Purposed HV reconstruction methods expand anatomical indication and makes 100% of relative donors eligible for LLS donation.

Impact of the introduction of laparoscopic liver resection as a surgical option for small/medium-sized (< 8 cm) tumors located in the left lateral section of the liver

Impact of the introduction of laparoscopic liver resection as a surgical option for small/medium-sized (< 8 cm) tumors located in the left lateral section of the liver

Intrahepatic pseudocyst following acute panceatitis: Report of a case

Introduction: Pancreatic pseudocysts are a common complication of acute pancreatitis. Most commonly, pseudocysts are located in the lesser sac and the retroperitoneum. The intrahepatic location of a pseudocyst is a rare event. Herein, we report a case of intrahepatic pseudocyst, located in left hepatic lobe, following acute pancreatitis. Case report: A 70-year-old woman was referred to out hospital with a upper abdominal pain of 3 days' duration. An abdominal CT scan revealed a 11 × 10 cm sized cystic mass in the left lateral section of liver. On EUS findings, a huge hypoechoic lesion was noted with internal echogenicity in the lesser sac. When the cystic lesion was punctured, dark green colored turbid fluid was aspirated. An EUS-guided gastrocystostomy was performed. The cystic fluid analysis showed a high level of amylase in the fluid collection. (21,200 U/L) After the endoscopic procedure, a severe abdominal pain was developed. Physical examination revealed severe tenderness and rebound tenderness. An emergency left hemihepatectomy was performed. On operation findings, a huge cystic tumor was located in the left lateral section of liver. It did not communicated with pancreas or peripancreatic tissue. However, mass-like necrotic tissue was filled with in the hepatoduodenal ligament, hepatogastric ligament, and Glisson sheath of the left hepatic lobe. Pathologic examination confirmed the pseudocyst by proving nonepithelialized granulation tissue of the cystic wall. Conclusion: The presence of intrahepatic cystic lesions in patients with acute pancreatitis should raise the possibility of intrahepatic pseudocysts, even when they are not associated with pancreas or peripancreatic tissue.

«LARGE-FOR-SIZE» LIVER LEFT LATERAL SECTION GRAFTS IN INFANTS

Transplantation of liver left lateral section (LLS) firmly established itself as a radical and effective method of treatment of advanced diffuse and unresectable focal liver diseases in pediatric patients. At the same time surgical community faced the challenge of matching the size of the adult donor’s graft to the volume of the child’s abdomen. Review of the literature presents historical aspects of transplantology, some approaches to measurement of the required liver parenchyma functional mass and methods to prevent complications associated with the usage of large LLS grafts in infants. In addition, the latest data on estimation of intra-abdominal pressure and development of intra-abdominal hypertension syndrome are also presented.

Laparoscopic Liver Resection for Tumors in the Left Lateral Liver Section.

Background:The laparoscopic approach is increasingly adopted for liver resections today especially for lesions located in the left lateral liver section. This study was conducted to determine the impact of the introduction of laparoscopic liver resection (LLR) as a surgical option for suspected small- to medium-sized (<8 cm) tumors located in the left lateral section (LLS).Methods:This is a retrospective review of 156 consecutive patients who underwent LLR or open liver resection (OLR) of tumors located in the LLS. The study was divided into 2 consecutive periods (period 1, January 2003 through September 2006, and period 2, October 2006 through April 2014); LLR was available as a surgical option only in the latter period. Comparisons made were LLR versus OLR, LLR versus OLR (in period 2 only), and resections performed in period 1 versus period 2.Results:Forty-two patients underwent LLR with 4 conversions. LLR was significantly associated with a longer median operative time [167.5 minutes (range, 60–525) vs 105 minutes (range, 40–235); P < .001], decreased need for the Pringle maneuver [n = 1 (2%) vs 22 (19%); P = .008], and shorter postoperative stay [n = 4 (range, 1–10) days vs 5 days (range, 2–47); P < .001] compared with open resection. Comparison of the 42 patients who underwent LLR with the 64 contemporaneous patients who underwent OLR demonstrated similar outcomes. Again, LLR was associated with a significantly longer operation, decreased need for the Pringle maneuver, and shorter hospital stay.Conclusions:LLR can be safely adopted to treat lesions in the LLS. The procedure is associated with a shorter postoperative stay and a decreased need for the Pringle maneuver, but longer operative time compared with that required for OLR.