Portal Vein Anastomosis Research Articles

One-shot side-to-side anastomosis (OSSSA) with stapler for cavo-cavostomy in liver transplantation: the first step towards a fully mechanized liver transplant?

In literature, a variety of caval reconstruction techniques for liver transplantation have been reported. The piggyback technique preserves the recipient's caval vein which is directly anastomosed to donor's inferior vena cava (IVC) allowing for the reduction of hemodynamic compromise during liver transplantation. Herein, we present our standardized step-by-step technique for the realization of a caval one-shot side-to-side anastomosis (OSSSA) using a linear stapler. A Satinsky vascular clamp is placed in a top down direction to realize a longitudinal partial clamping of the recipient IVC. A 1-cm venotomy is then performed on the anterior wall of the recipient IVC to permit the easy introduction of the vascular stapler arm in order to perform the mechanical anastomosis. Portal vein, hepatic artery, and biliary anastomosis are then completed in standard fashion. Compared to the manual one, this mechanical anastomosis permits to reduce operative time, caval and portal vein clamping, warm ischemia time, and visceral congestion. In our opinion, this is a rapid, easy, safe, and reproducible technique to perform the side-to-side cavocaval anastomosis during liver transplantation in selected patients when a manual anastomosis may be technically challenging.

Different Timing of Cholangiocyte and Hepatocyte Damage in Liver Preservation: Time to Implement Donor Interventions and New Preservation Techniques to Prevent Ischemic-type Biliary Lesions.

We read with interest the article by Gilbo et al1 assessing the impact of donor hepatectomy and implantation time on the incidence of early allograft dysfunction (EAD) and nonanastomotic strictures (NASs) in liver transplantation (LT). Donor hepatectomy and implantation time seem to have a linear negative impact on the incidence of NAS and EAD, respectively. A 10-min increase in either of these times is roughly as detrimental as a 1-h increase of cold ischemia time. This article expands our understanding of the importance of warm ischemia in LT, confirming findings from previous studies.2 We would like to provide further data and share our comments on this inspiring article. In 2016–1017, we collected data about times and graft temperatures in 160 first adult LTs with grafts from brain-dead donors. Liver temperature was measured at different time points using an infrared thermometer. In our experience, we were unable to show a significant impact of donor hepatectomy and implantation time on LT outcome, likely because of limited sample size and different practices that led to very little variability of these parameters. Median (interquartile range) time of donor hepatectomy and portal vein anastomosis was 47 (40–55) and 24 (21–28) min, respectively, and correlated poorly with graft temperature at the end of donor hepatectomy (R = 0.03, P = 0.61) and before graft reperfusion into recipient (R = 0.11, P = 0.16). However, our data (Figure 1) clearly show that liver grafts do suffer from a period of warm ischemia during retrieval and implantation.FIGURE 1.: Boxplot showing liver graft temperature at different time points during retrieval, back table preparation, and implantation. IQR, interquartile range.Analysis of EAD predictors in the study by Gilbo et al was somewhat hampered by the lack of inclusion of potentially important confounders, like macrosteatosis and severity of liver disease. Moreover, blood transfusions and early thrombotic events are also main determinants of EAD, as demonstrated by their incorporation in the recently developed early allograft failure simplified estimation score.3 Nonetheless, this study interestingly suggests that donor and recipient warm ischemia may impact differently on cholangiocytes and hepatocytes. Indeed, donor hepatectomy time had no effect on EAD (which is mainly determined by hepatocytes function), whereas implantation time was irrelevant with regard to NAS, which reflects cholangiocytes damage. Thus, cholangiocyte injury seems to happen at an earlier timing during graft retrieval and preservation, a finding in keeping with observations that histological damage to biliary epithelium and peribiliary glands is already apparent before graft reperfusion. As a logical implication, interventions focused on the earlier phase of organ preservation are likely needed to tackle NAS, especially in donors after circulatory death, a setting in which normothermic regional perfusion and hypothermic oxygenated machine perfusion have been associated with a significant NAS reduction.4,5 Besides underscoring once more the importance of proper training and technique in LT, this study confirms the role of ischemia-reperfusion injury in determining NAS and highlights the need to implement donor and preservation strategies to reduce their incidence. Future studies will have to assess whether the detrimental role of donor hepatectomy and implantation time persists also when alternative retrieval or preservation modalities are used.

Back-table surgery pancreas allograft for transplantation: Implications in complications.

To describe the main aspects of back-table surgery in pancreatic graft and the problems arising from poor technique. Back-table surgery for pancreatic graft is a complex, meticulous and laborious technique on which the success of implant surgery and perioperative results depends. The technique can be described in the following steps: Preparation of the sterile table, ex-situ inspection of the pancreas-spleen block, management of the duodenum, identification of the bile duct, preparation of the portal vein, preparation of the own graft arteries and anastomosis to the arterial graft, spleen management and graft preservation prior to implantation in the recipient. A careful inspection of the pancreas-spleen block should be performed. It is important to identify the stump of the main bile duct, the portal vein cuff, and the arrangement of the superior mesenteric artery and splenic artery. The redundant duodenum must be removed. The availability of a good venous cuff facilitates the portal vein anastomosis and the positioning of the graft, two key points to prevent thrombosis. The section line of the arteries must be clean, without atherosclerosis, to prevent arterial thrombosis. The superior and splenic mesenteric arteries are generally separated by dense fibrolymphatic tissue. The artery can be reconstructed by interposing a "Y" graft from the donor iliac artery; or with an end-to-end anastomosis between the splenic artery and the superior mesenteric artery. An exquisite technique of bench work helps to prevent the most feared complications of pancreas transplantation: Thrombosis and graft pancreatitis.

Impact of prolonged clamping of the portal vein during liver transplantation in infants with biliary atresia: renewed interest in a long-standing issue.

Various approaches to portal vein (PV) reconstruction have been described; however, there is still scope to improve the safety and efficiency of how PV anastomosis is performed in infants. We analyzed, retrospectively, the predictive factors for PV reanastomosis during living donor liver transplantation (LDLT) in 117 infants (< 1year old) with biliary atresia (BA). Twenty-six infants required PV reanastomosis because of intraoperative PV thrombosis in 21 and insufficient PV flow in 5. Univariate analysis identified multiple previous laparotomies and a prolonged anhepatic phase (AHP) as significant risk factors for repeated PV anastomosis. The AHP cutoff value for identifying patients requiring PV reanastomosis was 134min. Multivariate analysis revealed prolonged AHP > 134min (odds ratio, 15.98; 95% confidence interval, 5.05-50.6; P < 0.001) as an independent risk factor for repeated PV anastomosis. The plasma D-dimer and fibrinogen degradation product concentration just after reperfusion were significantly higher in patients requiring PV reanastomosis (P < 0.001). Patients requiring reanastomosis of the PV had a higher incidence of PV complications after LDLT than those who did not need PV reanastomosis (P = 0.01). Attempting to minimize the AHP is indispensable for successful LDLT in infants with BA.

Approach for outflow reconstruction and reperfusion in LDLT with a right lobe graft

Presenter: Nicolas Goldaracena MD | University of Virginia Health System Background: Living donor liver transplantation (LDLT) emerged to overcome the organ shortage and reduce waitlist mortality. However, is a technically demanding operation that requires careful preoperative preparation, as well as a meticulous surgery. To reduce the risk of small for size syndrome, a balance between a sufficient graft size, the degree of the recipient’s portal hypertension and adequate outflow reconstruction to avoid venous congestion of the graft are mandatory. Different approaches are being utilized to perform an optimal outflow reconstruction during LDLT. However, proper graft positioning, enlarged outflow openings and reconstruction of venous outflow of all liver sectors are crucial to achieve a congestion-free graft. Methods: A video abstract is presented illustrating the approach used for venous outflow reconstruction and graft reperfusion during LDLT with a right lobe graft. Results: The living donor graft consisted of a right lobe without the middle hepatic vein (MHV). As venous outflow, the graft had a dominant right hepatic vein (RHV), an accessory segment 6/7 vein and a segment 8 vein that needed reconstruction for optimal graft venous drainage. The approach used consists of performing a total caval clamping that facilitates a wide opening of the recipient’s vena cava, as anastomosis sites, while ensuring an optimal graft positioning and orientation. Once the RHV and segment 6/7 vein are reconstructed, the outflow of the anterior sector (segment 8 vein) is temporarily clamped to be reconstructed sequentially to the MHV following graft reperfusion. Therefore, portal vein anastomosis is then performed and following the release of the caval clamps the graft is reperfused via the portal vein. Once the graft is reperfused, the anastomoses of the graft segment 8 vein to the recipient’s MHV is performed with an interposition cadaveric iliac vein that was previously anastomosed to the segment 8 vein of the graft in the backtable. Conclusion: In our opinion, total caval clamping in LDLT ensures the possibility of providing enlarged outflow openings without compromising graft positioning and orientation. Therefore, this approach allows an optimal venous outflow and a congestion free graft in LDLT. In addition, in order to shorten the total caval clamping time, sequential reconstruction of the anterior sector veins of right lobe grafts can be safely performed following reperfusion of the graft.

An investigation on the renal portal system in long-legged buzzard (Buteo rufinus)

This study was carried out for the morphological examination of renal portal system in the long-legged buzzard. A total of nine adult long-legged buzzards were used in the study. The latex procedure was performed for the macroanatomic detection of the vessels forming the renal portal system. Dissections were performed under the stereomicroscope and later photographs were taken. The renal portal system vessels formed by the cranial renal portal vein and caudal renal portal vein in the long-legged buzzard. Afferent renal branches were separated from these vessels and efferent renal branches were observed to join renal veins. The anastomosis of the left cranial renal portal vein and right cranial renal portal vein was not observed at the cranial side, besides the presence of interiliac anastomosis was determined between the right internal iliac vein and left internal iliac vein at the caudal side. The findings of the renal portal system of long-legged buzzard (Buteo rufinus) were generally similar to those noted in other birds.

PORTAL AND ARTERIAL REPERFUSION DURING LIVER TRANSPLANT: A COMPARISON BETWEEN THE SIMULTANEOUS AND SEQUENTIAL TECHNIQUES

Introduction: A critical step in the liver transplantation procedure is the reperfusion of the liver graft after being connected to the circulatory system of the receptor. There are two possible techniques for the reperfusion: it may occur immediately after the portal vein anastomosis has been completed, with revascularization of the graft with blood from the portal system first, and then with arterial blood after the completion of the arterial anastomosis, in what is usually referred to as the sequential technique; or the reperfusion can occur only after both portal and arterial anastomosis have been completed, in what is referred to as the simultaneous technique. There is significant debate in the literature on whether one of these techniques offer advantages over the other, with studies pointing to a reduction of biliary complications with use of the simultaneous technique, while other studies failed to show any improvement. We present an analysis of 100 liver transplants performed using each technique, consisting in the largest single-center study on this subject performed so far. Materials and Methods: We analyzed 200 liver transplants performed on a tertiary Brazilian hospital during the 2014 to 2017 period, with 100 transplants using the sequential technique being performed immediately before 100 transplants using the simultaneous technique. All procedures used whole liver grafts procured from cadaveric donors. Statistical analysis was performed using Yates corrected Pearson’s chi-square for qualitative parameters and t test for quantitative parameters. Results: There was a significant difference in blood products transfusion between the two groups, with a mean of 1.11 units in the sequential perfusion (SeP) group, as opposed to 0.59 in the simultaneous perfusion (SiP) group (p=0.02). There was also a statistically significant difference in total procedure time, with an average of 398 minutes in the SeP group vs. 368 in the SiP group (p=0.0001); total ischemia time, with an average of 421 minutes in the SeP group vs. 472 minutes in the SiP group (p=0.002); and receptor age, with a mean of 51.1 years in the SeP group vs. 54.3 in the SiP group (p=0.03). No difference was found in mortality or biliary stenosis between the two groups. Discussion: While there was an increase in total ischemia time associated with SiP, due to the additional time in completing the arterial anastomosis before reperfusion, there was no negative impact in patient mortality or morbidity. Reduction in total operative time and intraoperative transfusion may be associated with quicker hemostasis and liver function in SiP. Conclusion: The use of the simultaneous reperfusion technique in liver transplant, while having no direct impact on patient mortality, may decrease total procedure time and need for intraoperative blood transfusion. The expected increase in total ischemia time with the use of the simultaneous technique does not appear to increase patient morbidity or mortality.

Techniques for overcoming atretic changes of the portal vein in living donor liver transplantation

BackgroundSpontaneous diversion of the portal flow through collateral vessels into the systemic circulation is frequently observed in liver transplant recipients with severe portal hypertension. This induces main portal vein atretic change and modifies flow into the collateral even after donor graft implantation. These atretic changes make liver transplantation challenging. In this article we described several methods for overcoming this challenge by appropriate surgical techniques. MethodsThree anastomotic techniques for living donor liver transplantation were performed in patients with atretic changes in the portal vein. ResultsThe three techniques were (1) venoplasty to widen the diameter by using the recipient's portal vein, and the diameter of the recipient's portal vein was enlarged using their own portal vein stump patch; (2) conduit with cryopreserved vessels, and we dissected around the superior mesenteric vein and splenic vein junction and a conduit was built using the cryopreserved vessels; and (3) left gastric varix to portal vein anastomosis, if the recipients had large gastric varix and variceal wall was sufficiently thick for anastomosis. ConclusionsSelection of optimal methods for portal vein anastomosis is essential in patients with atrophic change on the portal vein. If these methods are used aptly, they can be considered as favorable methods for overcoming each situation.

AIUM Practice Parameter for the Performance of an Ultrasound Examination of Solid-Organ Transplants.

AIUM Practice Parameter for the Performance of an Ultrasound Examination of Solid-Organ Transplants.

Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation

BackgroundPercutaneous trans-splenic portal vein recanalization (PVR) has been reported for facilitation of transjugular intrahepatic portosystemic shunts (TIPS), however has not been applied to patients undergoing direct intrahepatic portosystemic shunt (DIPS). We report the utilization of trans-splenic-PVR with DIPS creation in a patient with chronic portal and hepatic vein occlusions undergoing liver transplantation evaluation.Case presentationA 48-year-old male with decompensated alcoholic cirrhosis complicated by refractory ascites, hepatic encephalopathy, and variceal bleeding underwent CT that demonstrated chronic occlusion of the hepatic veins (HV), extrahepatic portal vein (PV), and superior mesenteric vein (SMV). Due to failed attempts at TIPS at outside institutions, interventional radiology was consulted for portal vein recanalization (PVR) with TIPS to treat the portal hypertension and ascites and also facilitate an end-to-end PV anastomosis at transplantation. After an initial hepatic venogram confirmed chronic HV occlusion, a DIPS with trans-splenic PVR was planned. The splenic vein was accessed under sonographic guidance using a micropuncture set and subsequently upsized to a 6 French sheath over a stiff guidewire. A splenic venogram via this access confirmed occlusion of the PV with drainage of the splenic vein (SV) through gastric varices. The thrombosed PV was then recanalized and angioplastied to restore PV flow via the transsplenic approach. A transjugular liver access kit with a modified 21-gauge needle was advanced into the IVC through the internal jugular vein (IJV) sheath and directed towards the target snare in PV. The needle was used to subsequently puncture the PV through the caudate lobe and facilitate placement of a wire into the SV. The initial portosystemic gradient (PSG) was 20 mmHg. The IJV sheath was advanced through the hepatic parenchymal tract into the main-PV and a stent-graft was placed across the main PV and into the IVC. A portal venogram demonstrated brisk blood flow through the DIPS, resolution of varices and a PSG of 8 mmHg. One month after the procedure, the patient had a significant reduction in ascites and MELD-NA score. Patient is currently listed and awaiting transplantation.ConclusionsIn the setting of chronically occluded portal and hepatic veins, trans-splenic PVR DIPS may serve as an effective bridge to liver transplantation by facilitating an end to end portal vein anastomosis.

Biliary reconstruction before clamp removal to avoid portal vein thrombosis in pediatric living-donor liver transplantation using hyper-reduced left lateral segment grafts: A novel technical strategy.

LT has become the treatment of choice for children with end-stage liver disease. The scarcity of donors and the considerable mortality on waiting lists have propelled the related living-donor techniques, especially in small children. This population need smaller and good quality grafts and are usually candidates to receive a LLS from a related donor. Many times this grafts are still large and do not fit in the receptor's abdomen, so a further hyper-reduction may be required. Despite all advances in LT field, vascular complications still occur in a considerable proportion remaining as a significant cause of morbidity, graft loss, and mortality. Technical issues currently play an essential role in its genesis. The widely spread technique for biliary and vascular reconstruction in living donor LT (LDLT) nowadays implies removal of the portal vein (PV) clamp after the venous anastomosis, then the arterial reconstruction is done, followed by the biliary reconstruction. However, due to the posterior location of the LLS bile duct, for its reconstruction, a rotation of the liver is required risking a potential transient PV occlusion leading to thrombosis afterward. We describe a new technique that involves performing biliary reconstruction after the PV anastomosis and before removing the vascular clamp, thus allowing to freely rotate the liver with less risk of PV occlusion and thrombosis.

Temporary Right Portocaval Shunt During Piggyback Liver Transplantation.

During piggyback liver transplantation (LT), a temporary end-to-side portocaval anastomosis (PCA) facilitates native total hepatectomy while maintaining hemodynamic stability. Some argue that PCA, performed on the main portal trunk (PT), might shorten the main portal vein and could cause technical difficulties during LT. We describe a temporary PCA performed on the right portal vein (R-PCA). The technique entails complete dissection of the main portal trunk up its right and left branches. After having ligated the left portal vein, the right is anastomosed end-to-side to the anterior face of the inferior vena cava. Taken down of R-PCA, before graft-recipient portal vein anastomosis, is achieved by stapling or suturing. An R-PCA has been performed in 14 over 15 planned procedures at our unit. In one case, because of intraoperative difficulties the PCA was performed on the PT. A temporary R-PCA represents a feasible alternative method of portal decompression during LT. Its use can be implemented into the technical armamentarium of transplant surgeons.

Liver Transplant in Patients With Portal Vein Thrombosis: The Experience of 55 Patients.

Portal vein thrombosis is no longer a contraindication for liver transplantation. However, varied outcomes are still reported with regard to patients with complete portal vein thrombosis. We analyzed data of 505 patients who underwent liver transplant between January 2014 and June 2017. Of 505 patients, 55 (10.9%) had portal vein thrombosis, which included 37 patients (67%) who had living-donor and 18 patients (33%) who had deceased-donor liver transplant. According to Yerdel classification, 5 (9%), 28 (51%), 12 (22%), and 10 patients (18%) had grade I, II, III, and IV portal vein thrombosis, respectively. Thrombectomy was successful in 46 patients (84%). Forty-three patients had patent portal inflow (93.5%), but 3 patients (6.5%) required a second thrombectomy on day 1 posttransplant. Of 10 patients with grade IV portal vein thrombosis, 9 (16%) underwent extra-anatomic portal vein anastomosis. Of these 9 patients, 7 (77.7%) showed patent portal inflow during the early postoperative period. Median follow-up time was 15.5 ± 13.1 months. During this time, portal vein stenosis was detected in 5 patients. Risk of repeat thrombosis was not significantly different between patients with deceased-donor and patients with living-donor liver transplant. Overall patient survival rates for patients with and without portal vein thrombosis were 73% (40/55) and 84% (376/450), respectively, which showed significant difference (P = .05). In contrast to early-grade portal vein thrombosis, complete portal vein thrombosis still provides a treatment challenge with high risk of morbidity and poor early outcomes in liver transplant recipients.

Domino Liver Transplant in Maple Syrup Urine Disease: Technical Details of Cases in Which the First Surgery Involved a Living Donor.

Data describing the technical aspects of living donor (LD) domino liver transplantation (DLT) in maple syrup urine disease (MSUD) are limited. The largest published series includes only 3 cases. One great challenge of this procedure is to ensure adequate vascular stumps for the LD, the MSUD patient, and the recipient of the domino graft. Here, we describe our experience in 11 cases of LD-DLT in MSUD, highlighting the technical aspects of LD-DLT. From September 2012 to September 2017, 11 patients with MSUD underwent LD liver transplantation at our institution, and MSUD livers were used as domino grafts in 11 children. (1) MSUD patients: 10 patients received a left lateral segment. The donor's left hepatic vein (HV) was anastomosed to the confluence of the recipient's 3 HVs. No vascular grafts (VG) were required for portal vein (PV) anastomosis. Single arterial anastomosis was performed with microsurgery in 10 of 11 patients. (2) MSUD graft recipients: In 8 cases, HV reconstruction was performed between the graft's HV confluence and the recipient's HV confluence, and in 3 cases, a vena cava triangulation was necessary; 6 MSUD grafts required HV venoplasty. No VG were needed for HV reconstruction. VG were used for PV reconstruction in 3 cases due to sclerotic PV. In 2 cases, double arterial anastomoses were performed in the MSUD liver. All patients remain alive and well. Living donor liver transplantation followed by DLT for MSUD is a complex procedure and demands technical refinement. Special attention must be paid to vascular reconstruction.

Using of Wearable Recording Technology for Surgical Training Video in Living Donor Liver Transplantation

Introduction: As surgical video recording technology has developed, trainee education using educational video has been made.In case of laparotomy, video recording system using a surgical video crane has been introduced and many surgeons present own video in congress or society meetings. However, the view in the surgical field is different from that of the surgical video, and the view of the 1st assistant is also slightly different from the video image. In addition, when the first assistant or operator concentrates the focus on the field, it is difficult to actually capture what their hands are doing. In other words, recorded video has a limitation in terms of education because it does not carry all the role of the participant. Method: A head mount was used to fix the camera on the operating surgeon's head. The recorded video was subsequently edited and used as a teaching tool. The procedure recorded were recipient hepatectomy, hepatic vein anastomosis, portal vein anastomosis, hepatic artery anastomosis, bile duct anastomosis. Each video clip were edited for trainee education including indicator, subtitles and narration. Result: The recorded video clips were high quality, which allowed for zooming and visualization of the surgical anatomy clearly. The camera can be mounted on the surgeon's head, so we could get a view of surgeons or 1st assistant. The trainees were able to perform image training through video before entering the surgery and showed a little more adaptation to surgery. Conclusion: Head-mounted action camera video recording system is a good model for making high quality, educational video module, and can be a useful teaching tool in living donor liver transplantation surgery.

Early experience of laparoscopic liver resection: A single institution experience with 37 consecutive cases.

Backgrounds/AimsLaparoscopic liver resection (LLR) has evolved and broadened in scope. While open liver resections are currently being performed safely in our hospital, LLRs are being implemented in fewer cases. The aim of this study was to review our initial experience in LLR to assess early outcomes of the procedure.MethodsA retrospective chart review was conducted for 37 patients who underwent laparoscopic liver resections for various indications between January 2014 and July 2017 by a single surgeon who had performed 161 open liver resections and 50 live donor hepatectomies during the same period.ResultsOf 37 laparoscopic liver resections performed, male to female ratio was 23 to 4. Their mean age was 61.4 years. There were 13 cases of wedge resections, 7 cases of left lateral sectionectomy, 9 cases of left hepatectomy, and 8 cases of right hepatectomy. Pathology included hepatocellular carcinoma (n=20), cholangiocarcinoma (n=3), intrahepatic duct stones (n=6), metastatic liver carcinoma (n=6), primary neuroendocrine tumor of liver (n=1), and huge hemangioma (n=1). The mean operation time was 174.7 minutes (range, 40–410 minutes). Mean blood loss was 200.5 ml (range, 10–2200 ml). There were no open-conversion cases. There were no intraoperative or postoperative complications except that a case of severe portal vein stenosis in the laparoscopic right hepatectomy occurred postoperatively. The patient underwent reoperation (portal vein resection and anastomosis, stenting). The mean hospital stay was 8.7 days (range, 2–44 days).ConclusionsEven though our experience in laparoscopic liver resection is still developing, our results are comparable to those of other studies. Therefore, an experienced surgeon in performing open liver resection should be able to perform the laparoscopic liver resection safely.

Analysis of risk factors for portal vein thrombosis after liver resection.

PurposeWe evaluated the risk factors for posthepatectomy thrombosis including portal vein thrombosis (PVT) and clinical outcomes.MethodsWe retrospectively analyzed 563 patients who had undergone hepatectomy from February 2009 to December 2014. Twenty-nine patients with preoperatively confirmed thrombosis and tumor recurrence-related thrombosis were excluded. We identified the location of the thrombosis as main portal vein (MPV), peripheral portal vein (PPV) and other site such as hepatic vein or inferior vena cava. Patients with MPV thrombosis and PPV thrombosis with main portal flow disturbance were treated with anticoagulation therapy. We performed operative thrombectomy before anticoagulation therapy who did combined portal vein (PV) segmental resection.ResultsOf the 534 patients, 22 (4.1%) developed posthepatectomy thrombosis after hepatectomy. Among them, 19 (86.4%) had PVT. The mean duration of Pringle's maneuver was significant longer in the PVT group than the no-thrombosis group (P = 0.020). Patients who underwent combined PV segmental resection during hepatectomy were more likely to develop posthepatectomy PVT (P = 0.001). Thirteen patients who had MPV thrombosis and PPV thrombosis with main portal flow disturbance received anticoagulation therapy immediately after diagnosis and all of them were improved. Among them, 2 patients who developed PVT at the PV anastomosis site after PV segmental resection, underwent operative thrombectomy before anticoagulation therapy and both were improved. There were no patients who developed complications related to anticoagulation therapy.ConclusionLong duration of Pringle's maneuver and PV segmental resection were risk factors. Anticoagulation therapy or operative thrombectomy should be considered for PVT without contraindications.

Liver Transplant From a Donor With Situs Inversus Totalis Using Orthotopic and Retroversus Technique: A Case Report

Situs inversus totalis is an infrequent genetic malformation affecting 0.01% of the population and consists of the total rotation of the organs 180 degrees, generating the so-called mirror-image reversal. For many years donors with this pathology were discouraged from organ donation. We present a case of hepatic and renal transplantation using the 2 techniques described, orthotopic and retroversus. The recipient was a 69-year-old man with end-stage liver and kidney disease due to alcoholism and diabetes, respectively, and a Model for End-Stage Liver Disease score of 32. There was no mismatch between recipient and donor. The implant started with the piggy-back technique using the retroversus technique, generating a tense portal vein anastomosis due to the superior situation of the elements of the hepatic hilum, so it was decided to undo suprahepatic anastomosis with the orthotopic technique, rotating the liver on its axis, without complications. Roux-en-Y hepaticojejunoanastomosis was carried out. The patient was discharged 15 days after surgery with normalization of renal function. Although both techniques must be taken into account, the one that fits best for a particular recipient should be used, given the particularities of size and shape of the liver graft. This can take some art and creativity from the surgical team.

Thrombosis prophylaxis in pediatric liver transplantation: A systematic review.

AIMTo review current literature of thrombosis prophylaxis in pediatric liver transplantation (PLT) as thrombosis remains a critical complication.METHODSStudies were identified by electronic search of MEDLINE, EMBASE and Cochrane Library (CENTRAL) databases until March 2018. The search was supplemented by manually reviewing the references of included studies and the references of the main published systematic reviews on thrombosis and PLT. We excluded from this review case report, small case series, commentaries, conference abstracts, papers which describing less than 10 pediatric liver transplants/year and articles published before 1990. Two reviewers performed study selection independently, with disagreements solved through discussion and by the opinion of a third reviewer when necessary.RESULTSNine retrospective studies were included in this review. The overall quality of studies was poor. A pooled analysis of results from studies was not possible due to the retrospective design and heterogeneity of included studies. We found an incidence of portal vein thrombosis (PVT) ranging from 2% to 10% in pediatric living donor liver transplantation (LDLT) and from 4% to 33% in pediatric deceased donor liver transplantation (DDLT). Hepatic artery thrombosis (HAT) was observed mostly in mixed LDLT and DDLT pediatric population with an incidence ranging from 0% to 29%. In most of the studies Doppler ultrasonography was used as a first line diagnostic screening for thrombosis. Four different surgical techniques for portal vein anastomosis were reported with similar efficacy in terms of PVT reduction. Reduced size liver transplant was associated with a low risk of both PVT (incidence 4%) and HAT (incidence 0%, P < 0.05). Similarly, aortic arterial anastomosis without graft interposition and microsurgical hepatic arterial reconstruction were associated with a significant reduced HAT incidence (6% and 0%, respectively). According to our inclusion and exclusion criteria, we did not find eligible studies that evaluated pharmacological prevention of thrombosis.CONCLUSIONPoor quality retrospective studies show the use of tailored surgical strategies might be useful to reduce HAT and PVT after PLT; prospective studies are urgently needed.

Adult Living Donor Liver Transplantation for Patients With Portal Vein Thrombosis: A Single-center Experience.

BackgroundLiving donor liver transplantation (LDLT) for patients with portal vein thrombosis (PVT) is associated with several technical challenges for its complicated procedures and poor outcomes. Some institutions still consider preexisting PVT as a relatively contraindication for LDLT.MethodsBetween April 2010 and May 2016, 129 adults underwent LDLT at our institution, and 28 (21.7%) of whom had preexisting PVT. Portal vein thrombosis was diagnosed using preoperative imaging techniques and intraoperative findings. The characteristics and outcomes of the cases were retrospectively evaluated.ResultsThe type of PVT included Yerdel grade 1 in 21 (75.0%) cases, grade 2 in 3 (10.7%) cases, and grade 3 in 4 (14.3%) cases. There were no cases of Yerdel grade 4 PVT. After removing thrombus inside the vessel, we performed simple portal vein anastomosis in 25 (89.3%) cases, patch technique with vascular graft in 1 case (3.6%), and an interposition technique with vascular graft in 2 cases (7.1%). Compared with the non-PVT group, cold ischemic time was longer (P = 0.012) and the rate of postoperative PVT was higher (P = 0.001) in PVT group. In the comparison between the recipient without and with postoperative PVT, the existence of preoperative PVT was the independent risk factor in the multivariate analysis (hazard ratio, 7.511; 95% confidence interval 1.382-40.820; P = 0.020).ConclusionsAlthough it had a technically complicated operation, LDLT could be safely performed in the patients with PVT in our institution.