Reconstruction In Liver Transplantation Research Articles

Hepatic Artery Reconstruction Prevents Ischemic Graft Injury, Inhibits Graft Rejection, and Mediates Long-term Graft Acceptance in Rat Liver Transplantation

BackgroundHepatic artery (HA) reconstruction is performed in the clinical liver transplantation. MethodsWe assessed the importance of HA reconstruction in the success of liver transplantation. Orthotopic liver transplantation was performed without immunosspression from Lewis (RT1l) to Lewis rats (syngeneic transplantation) as well as Lewis to BN (RT1n) rats (allogeneic transplantation) with or without HA reconstruction. We examined graft function, pathology, and mRNA levels using DNA arrays in both arterialized and nonarterialized liver grafts. ResultsIn Lewis-to-Lewis syngeneic grafts, both the arterialized and nonarterialized grafts survived >120 days with normal graft function. lnfiltration of CD3+ T cells and CD68+ macrophages, marked bile duct proliferation with apoptotic epithelial cells, and expansion and increasing fibrosis of portal areas were evident in the nonarterialized grafts at day 120, although preservation of architecture was noted in the arterialized grafts. DNA array analysis of nonarterialized syngeneic grafts demonstrated the upregulation of mRNA of cell death-related proteins, cell cycle–related proteins, and inflammation-related proteins than those in arterialized grafts. Moreover, the arterialized Lewis-to-BN allogeneic grafts could survive for a long time with less severe graft dysfunction than those in non-arterialized allogeneic grafts. ConclusionsHA reconstruction in liver transplantation inhibited hypoxic injury and subsequent inflammation and bile duct proliferation, prevented the augmentation of T-cell–and antibody-mediated rejection, and mediated long-term graft acceptance. HA reconstruction is essential factor in the success of liver transplantation.

Choledochoduodenostomy as Biliary Reconstruction in Liver Transplantation

Introduction: Choledochoduodenostomy (CDS) has earlier been used for biliary reconstruction in gastroenterological surgery. There are few publications assessing CDS in orthotopic liver transplantation (OLT). Until present the standard method of bilioenteric reconstruction in OLT has been Roux-en-Y choledochojejunostomy (CDJ). There are several arguments in favor of CDS: The procedure is technically simple, and can be performed faster than CDJ. The anastomosis is easily accessible endoscopicallly, and anastomotic complications can often be resolved without reoperation. Endoscopic access to biliary/entero-entero anastomosis in CDJ is possible, but can be challenging. We present our initial experience with CDS, comparing results with CDJ. Methods: From Apr. 2009 to Sept. 2011, 31 patients received CDS during OLT, where duct-to-duct anastomosis was not indicated due to inflammatory biliary disease or anatomical conditions. CDS was chosen if the anastomosis could be performed without tension. As control group we identified 32 patients operated with standard CDJ immediately prior to the CDS cohort, from Oct. 2007 to Mar. 2009. All data were analyzed retrospectively. Early and late biliary complications were recorded. Results: There were no demographical differences between the CDS/CDJ groups. One critically ill patient in the CDS group was lost to follow up due to early death. The median MELD-score was equal in both groups (15/16). The diagnosis primary sclerosing cholangitis was predominant in both groups (73 %/83 %). All liver grafts were from deceased donors, median cold ischaemic times were 382/438 min respectively. During the early follow-up period (≤30days), anastomotic bile leakage occurred in 4 patients in each group (13%/12%). Anastomotic biliary obstruction occurred in 2 patients in each group (6%/6%). In the CDS group, biliary complications were successfully treated endoscopically with stents in 4 patients, 2 patients were re-operated. In the CDJ group 4 patients were re-operated, whereas 2 were stented endoscopically. One patient in each group was later re-transplanted due to non-biliary complications. In the CDS-group 5 (16%) patients experienced an infection considered to be possible cholangitis within 90 days, as opposed to 0 patients in the CDJ-group. All recovered after antibiotic treatment. Late anastomotic strictures have not been observed after CDS, one patient developed stricture after CDJ. Conclusions: Our data show that the risk of biliary complications with CDS is comparable to Roux-en-Y CDJ. CDS may increase the risk of cholangitis but this can usually be resolved with antibiotic treatment. We conclude that CDS is a safe method of biliary reconstruction in liver transplantation, when duct-to-duct anastomosis is not indicated.

The Risk Factors of Hepatic Artery Thrombosis on the Micros urgical Vascular Reconstruction in Liver Transplantation

The Risk Factors of Hepatic Artery Thrombosis on the Micros urgical Vascular Reconstruction in Liver Transplantation

Removable intraductal stenting in duct-to-duct biliary reconstruction in liver transplantation

Biliary reconstruction during liver transplantation (LT) is most oftenly performed by duct-to-duct biliary anastomosis. We hypothesized that the internal stenting might diminish the incidence and severity of biliary complications in patients receiving small duct size donor grafts. The purpose of this study was to report a technique of biliary reconstruction, including intraductal stent tube (IST) placement followed by postoperative endoscopic removal. A custom-made segment of a T-tube was placed into the bile in 20 patients in whom the diameter of the graft bile duct was smaller than 5 mm. The tube was removed endoscopically 4-8 months after LT, or in case of IST-related adverse events. After a median follow-up of 15.2 (range 2.5-27.5) months, endoscopic removal of the IST was performed in 17 patients. No technical failure and no procedure-related complications were recorded during drain removal. Biliary complications occurred in four patients, including one cholangitis, one hemobilia, one asymptomatic biliary leakage, and one anastomotic stricture. No biliary complication occurred in the group of patients who underwent deceased donor whole graft LT. IST is technically feasible and safe, and may help to prevent severe biliary complication when duct-to-duct biliary anastomosis is performed on small size bile ducts.

Hepatic Artery Thrombosis After Liver Transplantation: Three Case Reports

Objective To explore the surgical techniques of hepatic artery reconstruction in liver transplantation (OLT) and the choice of treatment for hepatic artery thrombosis (HAT). Methods We analyzed hepatic artery reconstructions based on 234 cadveric donor liver transplantations and seven living related liver transplantations from April 2003 to February 2009. Anastomosis time was compared between the groups with respect to vascular caliber. Interventional thrombolysis or early thrombectomy and hepatic artery reconstruction was implemented in three HAT cases. Results The hepatic artery anastomoses for vessels less than 3 mm in diameter ( n = 78) required 33.6 ± 21.3 minutes which were significantly greater compared with those for vessels more than 3 mm in diameter ( n = 163; 19.4 ± 7.4 minutes). Among two patients (0.83%) who developed early HAT within the first week after the operation, one was successfully treated by interventional thrombolysis, but the other required an urgent conduit between the aorta and the graft after attempted thrombolysis. Only one patient (0.41%) displayed a delayed HAT without special management, but recovered liver function upon follow-up. Discussion Early detection and proper revascularization measures can yield satisfactory results after HAT.

Systematic review and meta‐analysis of biliary reconstruction techniques in orthotopic deceased donor liver transplantation

Biliary complications remain a major cause of morbidity and mortality in liver transplantation and the biliary anastomosis technique could increase this risk. The aim of this study was to compare the effects of biliary reconstruction techniques in orthotopic liver transplantation on the incidence of biliary complications. A systematic review and meta-analysis using the Medline-PubMed, EMBASE, Scielo-LILACS, and Cochrane Databases were performed comparing biliary reconstruction techniques in liver transplantation with regard to the occurrence of biliary complications. Number needed to treat (NNT) was calculated at a 95% confidence interval. Fifty-seven articles were selected (3 randomized clinical trials, 6 clinical trials, and 48 historical cohort studies). There was a lower risk for biliary complications (NNT=6) using end-to-end choledochocholedochostomy (EECC) without drainage compared with EECC with drainage. The biliary complication risk was lower (NNT=4) for side-to-side choledochocholedochostomy (SSCC) with drainage compared with SSCC without drainage. No difference was found between EECC without drainage and SSCC with drainage. According to our results, considering the highest level of evidence available in the literature, we suggest that biliary reconstruction in liver transplantation should be performed using EECC or SSCC, without drainage in the former, and with drainage in the latter.

Patterns of portal reconstruction for liver transplantation in patients with diffuse portal and superior mesenteric venous thrombosis

Patterns of portal reconstruction for liver transplantation in patients with diffuse portal and superior mesenteric venous thrombosis

Choledochoduodenostomy as an Alternative to Choledochojejunostomy for Biliary Reconstruction in Liver Transplantation

We read with interest the article by Bennet et al., who advocated the use of choledochoduodenostomy (CDD) as an alternative method of achieving biliary drainage of the transplanted liver [1]. Although Wigmore had written a commentary for this article [2], we still have the following concerns. First, the criteria for entry in this study were not clear, particularly concerning the selection for those patients who underwent CDD or choledochoenterostomy. From the context of the article, the subjects for this study were not selected for CDD or choledochoenterostomy randomly. We think the selected criteria may influence the effects of the operations. The authors noted that no patient during followup had any anastomotic strictures or significant reflux and subsequent cholangitis. Were there any symptoms or signs suggesting partial reflux or stricture of the anastomosis during the postoperative period? Did the authors provide some interference? Second, a previous study showed that the postoperative recurrent cholangitis caused by CDD was observed mainly in patients with a narrow common bile duct (CBD) [3]. However, most CBDs in liver donors are in physiological condition, the diameters of which are less than those stated in the criteria. In their article, Bennett et al. noted that no patient during follow-up had subsequent cholangitis after the CDD. Just as the authors declaimed their brief followup may be a reason, we want to know whether they made some modification in the operative procedure that might lower the incidence of cholangitis. Third, we discovered that the line drawings of the CDD may be not precise. The remaining biliary tract of the donor was too long, which may cause necrosis of the proximal biliary tract due to a limited blood supply. Although these problems are minor, they may cause misconceptions by the readers.

Choledochoduodenostomy is a Safe Alternative to Roux‐en‐Y Choledochojejunostomy for Biliary Reconstruction in Liver Transplantation

Bile duct reconstruction during liver transplantation is usually performed by a duct-to-duct anastomosis or a Roux-en-Y choledochojejunostomy (CDJ). Direct anastomosis of the bile duct to the duodenum (choledochoduodenostomy-CDD) is another option for biliary reconstruction. This technique has been used with good outcome for the treatment of choledochal cysts, ampullary stenosis, and major bile duct injuries; however, there is little published experience with CDD in liver transplantation. We provide preliminary evidence that CDD is a safe technique for biliary anastomosis in liver transplant recipients. From September 2000 to August 2007 a total of 619 adult first-time cadaveric or living donor liver transplants were performed at the University of Colorado Health and Science Center. Bile duct repair was performed by direct end-to-end anastomosis in 466 patients and by choledocoenterostomy in the remaining 153 patients, 82 of whom were cadaveric recipients. The cadaveric choledocoenterostomy patients were divided into two groups: CDD in 25 and CDJ in 57 recipients. There were no significant differences in the 1-year patient or graft survival between the cadaveric groups. The 1-year patient survival was 100% in the CDD group and 97.1% in the CDJ group. The CDD group did not experience more surgical complications compared to the CDJ group. Choledochoduodenostomy is a safe alternative to CDJ biliary anastomosis when a duct-to-duct anastomosis cannot be performed. There is no significant difference in mortality, graft survival, or biliary complications. In addition, CDD offers the advantage of postoperative access to the billiary system by endoscopy and avoids complications associated with the CDJ bowel anastomosis.

Continuous Versus Interrupted Suture for Hepatic Artery Anastomosis in Liver Transplantation: Differences in the Incidence of Hepatic Artery Thrombosis

Background Hepatic artery thrombosis (HAT) is a serious complication after orthotopic liver transplantation (OLT) and remains a significant cause of graft loss. HAT following OLT has been reported in 3% to 9% of patients. Among the surgical factors considered to be associated with HAT, arterial reconstruction might be the most important. The goal of this study was to compare the incidence of HAT between interrupted suture (IS) and continuous suture (CS) techniques during hepatic artery reconstruction in liver transplantation. Methods We performed a retrospective analysis of 200 consecutive liver transplantations occurring between May 2002 and December 2006, including medical records for: age, gender, cold ischemic time, warm ischemic time, type and number of arterial anastomosis. Hepatic artery anastomoses were performed using a 7-0 prolene with a running CS in the first 105 patients (CS group), and with an IS in the last 95 patients (IS group). Results Statistical analysis of age, gender, cold and warm ischemia time, and number of hepatic artery anastomoses was not different between the CS and IS groups. Eleven episodes of HAT were identified in the CS group (10%) and two episodes (2%) in the IS cohort, a significant difference (P = .0173). Conclusions Our results suggested that IS might be a better choice for hepatic artery anastomosis with a lower incidence of HAT.

Techniques of biliary reconstruction for liver transplantation

Techniques of biliary reconstruction for liver transplantation

Intraoperative ultrasound guided portal venous thrombectomy in living donor liver transplantation recipient surgery

Portal vein reconstruction in liver transplantation from live donor grafts has major challenging factors in cases with portal venous thrombosis (PVT). To overcome this critical surgical challenge, we devised a novel technique, intraoperative ultrasonography (IOUS)-guided thrombectomy of the portal vein. IOUS-guided thrombectomy was applied to the 10 patients whose PVT extended to the splenomesenteric junction. In these patients, closed thin scissors were inserted from the stump of the recipient portal vein under ultrasound guidance and the thrombus was dissected from the venous wall. The application of IOUS-guided thrombectomy in patients with moderate to severe PVT led to a 3-year patency rate of 83%, comparable to that of simple thrombectomy applied to partial or minimal (grade I-II) PVT (83%). IOUS-guided thrombectomy is helpful to adequately remove severe thrombi from the deep lumen of the portal vein, provided the procedure was carried out by an experienced surgeon with adequate preparation for unexpected venous injuries.

Clinical trial on the cost‐effectiveness of T‐tube use in an established deceased donor liver transplantation program

The aim of our study was to assess the advantages and disadvantages of T-tube use in liver transplantation, with also paying attention to the economic costs derived from its use. Patients were prospectively randomized to T tube or no T tube. One hundred and seven patients, 53 with T tube and 54 without T tube, were analyzed. Minimum follow-up was three months. Nine patients (8.4%) had bile leak: six in the T-tube group (11.3%) and three in the group without T tube (5.5%), p = ns. Four patients (3.5%) had anastomotic biliary stenosis: one in the T-tube group (1.8%) and three in the group without T tube, p = ns. Twenty of the 53 patients (37.7%) with T tube had T-tube-related complication. The number of diagnostic and therapeutic resources were higher in the T-tube group compared with non-T tube (81 and 17 vs. 18 and 10, respectively, p <0.05). The costs of therapeutic procedures required for the treatment of complications were 28 232 euro in the T-tube group vs. 16 088 euro in the no T-tube group, p <0.05. In conclusion, the systematic use of the T tube in biliary reconstruction in liver transplantation cannot be justified.

Budd-Chiari–Induced Protein-Losing Enteropathy After Liver Transplantation

Budd-Chiari syndrome (BCS) is one of the uncommon complications of hepatic venous reconstruction in liver transplantation. Protein-losing enteropathy (PLE) secondary to this event has rarely been described. A 14-year-old girl suffering from acute hepatic failure underwent an emergency living-related liver transplantation and developed BCS 1 year later. Her condition has been managed with several sessions of hepatic venoplasty. On one occasion, she suffered septicemia and severe diarrhea, passing large amount of fibrinoid material. The diagnosis of PLE was made clinically, which resolved immediately after reestablishment of hepatic venous patency by balloon venoplasty. This observation suggested that BCS was responsible for PLE in this patient. Prompt diagnosis and early intervention for this life-threatening condition is essential.

Biliodigestive Anastomosis in Liver Transplantation: Review of 13 Years

Hepaticojejunostomy is a good alternative technique for biliary reconstruction in liver transplantation. Among 517 liver transplants performed between March 1992 and July 2005, 33 involved hepaticojejunostomy, namely, 18 men and 12 women of average age: 44.8 years. The main cause for this technique was retransplant ( n = 10), secondary biliary cirrhosis ( n = 5), alcoholic cirrhosis ( n = 5), HCV cirrhosis ( n = 2), primary biliary cirrhosis ( n = 1), cryptogenic cirrhosis ( n = 1), sclerosing cholangitis ( n = 3), fulminant liver failure ( n = 1), autoimmune cirrhosis ( n = 1), and insulinoma metastasis ( n = 1). Choledochojejunostomy was performed for all Roux-en-Y loops, with an average cold ischemia time of 361.16 minutes (180–780). The biliary complications were biliary fistula in four cases (13.3%), including two who required surgery; stenosis of the anastomosis in two cases (6.6%) including one diagnosed by HIDA that resolved with medical treatment and the other, diagnosed by cholangio-MRI, requiring a new hepaticojejunostomy; and biliary peritonitis in three cases (10%), all of whom required surgery. The vascular complications were thrombosis of the hepatic artery ( n = 1), which required retransplantation, and pseudoaneurysm of hepatic artery ( n = 1). No biliary complications occurred. The 6-month patient survival was 80% and the 6-month graft survival was 77%; no patient died due to biliary complications. Hepaticojejunostomy is a technique with higher morbidity than choledocho-choledochostomy, but it is the best alternative when the latter is not possible.

A New Technique for Bile Duct Reconstruction in Liver Transplantation

Biliary complications are one of the most important problems in liver transplantation. Despite various refinements of surgical technique, liver transplantation is associated with significant numbers of biliary problems. In this article, we describe our novel “intraoperative transhepatic biliary catheter insertion” technique for biliary reconstruction in 29 patients, since November 2004 comparing results before and after its implementation. 5-F Kumpe catheter is inserted into the biliary system in two steps. The first is completed at the back table, and the second during the recipient operation. The grafts were from cadavers in 10 cases, with the remaining ones from living donors. Ten patients received whole-liver grafts, 11 received a right lobe, and eight received a left-lateral lobe or left lobe. The mean weight of the living donor grafts was 598 g (range = 270 to 975 g). The mean graft weight-to-body weight ratio in the living donor liver transplantations was 1.6% ± 1.0% (range, 0.8% to 4.1%). Intraoperative transhepatic biliary catheter insertion was performed with a duct-to-duct anastomosis in 27 cases and with a Roux-en-Y hepaticojejunostomy in two cases. The only biliary complication was one case (3.4%) of bile leakage from the anastomotic site. This rate is significantly lower than that for duct-to-duct biliary reconstructions prior to the new catheter technique (13.0%; P < .05). This new technique of biliary reconstruction with intraoperative biliary catheter insertion has significantly reduced our biliary complication rate. Transhepatic biliary stenting prevents biliary complications and makes it simple to maintain percutaneous access in case such problems arise. However, further studies are needed to compare incidence rates of biliary complications when our novel technique is used versus other surgical techniques.

Surgical Complications and Long-Term Outcome of Different Biliary Reconstructions in Liver Transplantation for Primary Sclerosing Cholangitis—Choledochoduodenostomy versus Choledochojejunostomy

Choledochojejunostomy (CJS) is commonly used for biliary reconstruction in liver transplantation for primary sclerosing cholangitis (PSC). We alternatively performed choledochoduodenostomy (CDS) and side-to-side choledochodocholedochstomy in a large cohort of patients. Fifty-one patients with PSC, transplanted between 1988 and 2000, were analyzed retrospectively. Biliary reconstruction was CDS in 25 (49%), CJS in 20 (39%) and CC in 6 transplantations (12%). Biliary leaks occurred in the early follow-up (< or =41 days) only in CDS patients (20%). However, in the late follow-up (>4 months), stricturing of anastomosis was found once in CDS (4%) and CJS (5%). Later (>9 months), intrahepatic bile duct strictures were diagnosed in four CDS (16%), one CJS (5%) and one CC (17%) patient(s). In 48% of CDS (12/25), 60% of CJS (12/20) and 17% of CC (1/6) at least one incidence of cholangitis was observed. Overall, biliary complication rates were significantly higher in CDS (40%) than CJS (10%) and CC (17%); of those none in CC and 12% in CDS were anastomosis-related. Graft/patient survival showed no significant differences among groups. Based on our results we consider CJS the standard method for biliary reconstruction in PSC; however, in selected cases where CJS is difficult to accomplish because of previous surgery or for retransplantation, CDS may present an alternative technique.

The use of a composite graft of iliac artery and inferior mesenteric vein in liver transplantation

Innovation may be required for satisfactory arterial reconstruction in liver transplantation, particularly when the vessels obtained from the donor are inadequate. We have used a composite graft of donor iliac artery and recipient inferior mesenteric vein (IMV) between the infrarenal aorta and donor hepatic artery. Postoperative liver function was satisfactory, with normal daily duplex ultrasound scans for the first 2 weeks. At 4 years follow up, graft function is normal, a duplex ultrasound scan shows normal arterial flow and no dilatation of the composite graft, and a magnetic resonance angiogram reveals no evidence of dilatation or thrombosis of the composite graft. This is one of the few reported cases in which a composite graft has been used to arterialize the allograft in liver transplantation. A composite graft of iliac artery and IMV provided a satisfactory outcome in this patient and may be a valuable addition to the arterial grafts available to the liver transplant surgeon.

Outcome of hepatic artery reconstruction in liver transplantation with an iliac arterial interposition graft

In case of anomal hepatic arterial inflow, it can be necessary to perform revascularization of the liver allograft by iliac arterial interposition graft. We analyzed retrospectively 613 liver transplants in a 16-yr period. The hepatic artery (HA) graft group (n = 101) consisted of patients with arterial inflow based on recipient infrarenal aorta using donor iliac artery graft tunneled through the transverse mesocolon. The control group (n = 512) consisted of patients who underwent liver transplantation with routine HA reconstruction. Both groups are homogeneous and comparable. In case of retransplantation, arterial conduit with iliac graft was adopted more frequently instead of conventional arterial anastomosis (24.8% vs. 9%, p < 0.0001). The 1-, 3- and 5-yr overall survival was 85.41, 79.42, 76.57% in the control group and 76.21, 73.43, 73.43% in the HA graft group, respectively (p = ns). The 1-, 3- and 5-yr graft survival was better in the control group (81.51, 73.66, 69.22% vs. 71.17, 62.50, 53.42%) (p = 0.01). In case of retransplantation, the 1-, 3- and 5-yr overall (57.81, 53.95, 41.96% vs. 60, 51.95, 49.85%) and graft survival (57.52, 53.68, 41.75% vs. 56, 50.4, 40.3%) was similar in control and HA graft group, respectively (p = ns). Hepatic artery thrombosis (HAT) rate is 21.8% vs. 8.6% (p < 0.0001) in HA graft group and control group, respectively. The only factor independently predictive of early HAT resulted arterial conduit (p = 0.001, OR = 3.13, 95% CI: 1.57-6.21). Retransplant procedure, donor age and arterial iliac conduit were found to be a significant risk factors for late HAT, at univariate analysis. At multivariate analysis, donor age >50 yr old resulted the only factor independently associated with late HAT (p < 0.0001, OR = 1.05, 95% CI: 1.02-1.07). Iliac arterial interpositional graft is an alternative solution for arterial revascularization of liver allograft in case of retransplantation when the use of HA is not possible. In case of primary transplantation, is better not to perform arterial conduit if it is possible, for poor graft survival and high incidence of early HAT, especially in case of liver donor aged over 50 yr.

Roux-en-Y Choledochojejunostomy is the method of choice for biliary reconstruction in liver transplantation for primary sclerosing cholangitis.

Opinion is divided regarding the optimal method of biliary reconstruction after liver transplantation for primary sclerosing cholangitis (PSC). We investigated biliary complications and graft and patient survival in all patients who underwent liver transplantation for PSC in the United Kingdom between 1994 and 2003. Anastomotic leak rates were similar, but a significantly higher stricture rate was observed in patients who had a duct-to-duct reconstruction compared with those who underwent a Roux-en-Y anastomosis. Graft and patient survival were also markedly worse in patients with a duct-to-duct anastomosis. Roux-en-Y choledochojejunostomy is the method of choice for biliary reconstruction in liver transplantation for PSC.