Retrohepatic Vena Cava Research Articles

Anesthetic risks for donors in living-related liver transplantation: analysis of 30 cases.

Liver transplantation involving living-related donors has been adopted in many centers as a way of relieving organ shortage. This study reviewed the anesthetic considerations for donor operations at our institution in relation to intraoperative blood transfusion, complications, and postoperative liver function test results. From January 1990 to May 2001, 30 living-related liver transplantations were performed at Başkent University Hospital, Ankara. The donor data used for analysis were retrospectively obtained through chart review, anesthesia records, and the computerized hospital database. Left lobectomy was performed in 19 cases, and left lateral segmentectomy in 11 cases. Intraoperatively, the average volume of intravenous fluids used was 6431+/-468 ml, and the average amount of blood transfused was 2.1+/-0.4 units. The mean postoperative hospital stay was 11.5+/-1.3 days. The only intraoperative complication observed in these 30 donors was severe bleeding during retrohepatic vena cava dissection in one of the cases. The postoperative complications related to anesthesia were one case each of shoulder pain, neuropraxia, and compartment syndrome. The levels of total and direct bilirubin, aspartate aminotransferase, and alanine aminotransferase peaked within the first 2 postoperative days (2.19+/-0.36 mg/dl, 1.02+/-0.18 mg/dl, 245.7+/-26.6 U/l, 313.5+/-51.9 U/l, respectively). In all 30 donors, these levels had normalized by 1 month after surgery. Maximal efforts must be applied in the anesthetic approach to minimize donor complications in living-related liver transplantation; however, this will not completely eliminate some risks to the donor.

Management of massive and persistent ascites and/or hydrothorax after liver transplantation

PurposeTo describe the results of the treatment of eight liver transplantation (LT) patients subsequently developing large volumes of long-lasting ascites. Patients and methodsBetween August 1996 and February 2003, 405 LTs were performed in 375 patients, eight (1.97%) of whom (six men and two women of mean age of 55.4 ± 5.2 years) subsequently developed massive (> 500 mL/d) and persistent ascites and/or hydrothorax. All patients were HCV positive. The mean age of the liver donors was 66.8 ± 21.9 years. All LTs were performed by replacement of the recipient retrohepatic vena cava. ResultsThe eight patients displayed sinusoidal portal hypertension related to biopsy-proven recurrence of HCV infection. Mean wedged hepatic venous pressure was 14.9 ± 5.1 mm Hg and mean portal vein/right atrial pressure gradient (PAPG) was 17.3 ± 4.8 mm Hg. In two patients, the ascites appeared the day after LT; in the remaining six, ascites and/or hydrothorax appeared after 342.3 ± 167.7 days. Seven patients with a mean PAPG of 18.4 ± 3.9 mm Hg and a mean plasma/ascites albumin concentration gradient of 2.8 ± 0.3 g/L were treated by means of a trans-jugular intrahepatic portosystemic shunt TIPS, and one (with a PAPG of 9 mm Hg and a plasma/ascites albumin concentration gradient of 1.38 g/L) by means of spleen arterial embolisation. After a mean follow-up of 558 ± 147.2 days, the ascites and/or hydrothorax have resolved in five patients (62.5%), one (12.5%) has stable ascites not requiring paracentesis, and two (25%) have died of multiorgan failure. ConclusionThese data suggest the efficacy of the aggressive treatment of massive and persistent ascites and/or hydrothorax.

Hepatic Cryotherapy Involving the Vena cava

Liver tumors located near the retrohepatic vena cava are often considered nonresectable. For these patients cryoablation could be a therapeutic option. In this study the safety and efficacy of hepatic cryosurgery involving the retrohepatic vena cava were investigated. Cryolesions involving the vena cava were created in 26 pigs. Follow-up was 24 h and 14 days. The extent of the cryolesion, damage to the vena cava and complications were assessed after autopsy. The cyronecrosis extended into the wall of the vena cava in 81% of the animals. All animals had an uneventful recovery without any complications such as ruptures of the vessel, thrombosis or pulmonary embolism. Microscopically elastic and collagenous fibers of the cava wall remained intact. The continuity of the vessel wall was conserved. In conclusion, the safety and efficacy of cryosurgical treatment involving the retrohepatic vena cava were shown in a pig model.

Surgical Management of Advanced Malignant Adrenal Tumours

Background: Advanced adrenal carcinomas tend to infiltrate the adrenal vein and to grow intraluminally into the inferior vena cava, thereby diminishing or occluding the venous flow. Less often, tumour thrombi extend into the right atrium. Radical surgery requires caval or cavo-atrial thrombectomy while maintaining vascular control, complemented by multivisceral resections, if applicable. Methods: A review of the literature — undertaken in orcer to describe surgical techniques as well as postoperative results in the treatment of organ-exceeding adrenal cancer — and own experiences are the basis of management recommendations. Results: The extent of vascular involvement of adrenal neoplasms is classified into four different types, which require increasingly challenging surgical procedures. Low perioperative mortality and long tumour-free survival rates are reported in malignant phaeochromocytomas, adrenocortical malignancies, and other primary adrenal neoplasms such as leiomyosarcoma. Conclusions: Nowadays, advanced disease does not preclude the patient from radical surgical therapy in adrenal malignancies. Advances in vascular surgery and extracorporeal bypass techniques have led to the development of safe techniques for the removal of tumour thrombi, even of the retrohepatic and subdiaphragmatic vena cava. The poor prognosis of patients without resection or with incomplete tumour resections justifies an aggressive surgical approach.

Experience with an elective vacuum assisted cardiopulmonary bypass in the surgical treatment of renal neoplasms extending into the right atrium.

We evaluate the results of an elective cardiopulmonary bypass conceived to minimize the surgical risk related to its use with temporary circulatory arrest and deep hypothermia in the treatment of patients with renal tumor extending into the right atrium. From July 1996 to December 2000, 19 patients with renal neoplasm and venous involvement were admitted to our department. Three patients 4, 57 and 58 years old with a right (2) and left (1) renal tumor extending into the right atrium underwent radical nephrectomy and tumor thrombus removal using a normothermic cardiopulmonary bypass. The bypass circuit was connected with a vacuum assisted venous drainage giving a negative pressure of 20 to 40 mm. Hg. Neither circulatory arrest nor hypothermia was used. Tumor thrombus was extracted through a longitudinal "cavotomy" and removed along with the kidney. Total cardiopulmonary bypass time was 14, 19 and 22 minutes, respectively. No intraoperative or postoperative complications due to surgical technique occurred. No significant bleeding was observed at the time of cavotomy and all neoplastic tissue was removed. Pathological examination documented renal cell carcinoma in 2 cases and Wilms tumor in 1. All the patients are alive 30, 42 and 15 months, respectively, after the operation. Normothermic cardiopulmonary bypass with vacuum assisted venous drainage makes circulatory arrest and hypothermia unnecessary and avoids the potential complications associated with these procedures. With respect to veno-venous shunts this technique guarantees complete surgical control of the thrombus and avoids the need for extensive dissection of the retrohepatic vena cava and Pringle maneuver.

Prótese intracava provisória no tratamento de lesão da veia cava retro-hepática

One of the most difficult challenges to surgeons is the treatment of wounds on the retro hepatic vena cava. The anatomic particularities of this venous segment make its approach and treatment difficult, contributing to a high morbidity and mortality. Several techniques have been described for the treatment of these types of lesions. In this particular case, authors have chosen the introduction of a fastened provisory intra caval prothesis, without primary suturing of the wounds. The provisory intra caval prothesis can be an option for the treatment of retro hepatic vena cava lesions.

Splenosis Presenting as a Right Suprarenal Retroperitoneal Mass

No AccessJournal of UrologyCLINICAL UROLOGY: Case Reports1 Aug 2002Splenosis Presenting as a Right Suprarenal Retroperitoneal Mass Kent T. Perry, Amnon Zisman, Jennifer Singer, and Peter Schulam Kent T. PerryKent T. Perry More articles by this author , Amnon ZismanAmnon Zisman More articles by this author , Jennifer SingerJennifer Singer More articles by this author , and Peter SchulamPeter Schulam More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)64703-9AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Splenosis Presenting as a Right Suprarenal Retroperitoneal Mass." The Journal of Urology, 168(2), pp. 644–645 References 1 : [Peritoneal splenosis simulating a right retroperitoneal mass.]. J Radiol1998; 79: 1407. Google Scholar 2 : Autologous splenic transplantation for splenic trauma. Ann Surg1994; 219: 225. Google Scholar 3 : [A case of accessory spleen presenting as retroperitoneal tumor.]. Hinyokika Kiyo1998; 44: 711. Google Scholar From the Department of Urology, University of California, Los Angeles, California© 2002 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 168Issue 2August 2002Page: 644-645 Advertisement Copyright & Permissions© 2002 by American Urological Association, Inc.Keywordsspleenchoristomasplenosiswounds and injuriesMetricsAuthor Information Kent T. Perry More articles by this author Amnon Zisman More articles by this author Jennifer Singer More articles by this author Peter Schulam More articles by this author Expand All Advertisement PDF downloadLoading ...

Coagulation profiles and intraoperative substitution requirements during elective piggyback liver transplantation with prophylactic antifibrinolytic therapy.

During recent years, piggyback liver transplantation (pOLT) with preservation of the retrohepatic vena cava has been introduced in adults. The objective of this study was to evaluate hemostatic changes associated with this transplantation technique. Fifty-seven patients undergoing elective pOLT for endstage liver disease were studied. Most significant changes were observed after graft reperfusion, when PT showed a 49% decrease and activated partial thromboplastin time (aPTT) as well as TT a 2- to 3-fold prolongation. At the same time, factors of the extrinsic coagulation pathway (II, V, VII) revealed an overall 50% decline. Similar changes were observed for antithrombin III (ATIII) and fibrinogen plasma levels. However, only 42% of all patients required intraoperative substitution with coagulation components. There was an association between preoperative fibrinogen (<1.7 g/dl) and ATIII (<50%) plasma levels and the substitution requirement. Multiple linear regression showed a significant correlation between preoperative ATIII activity and intraoperative blood loss. Despite a marked impairment of hemostasis, pOLT can frequently be performed with minimized substitution therapy.

Resection of giant hepatic cavernous hemangiomas after dissection of the third porta hepatis

Objective To establish a novel and safe operation technique for the resection of giant hepatic cavernous hemangiomas involving the retrohepatic vena cava.

Injuries of the inferior vena cava

Injuries of the IVC, whether caused by blunt or penetrating mechanisms, are usually fatal. Patients who arrive in shock and fail to respond to initial resuscitative measures, those who are still actively bleeding at the time of laparotomy, and those with wounds of the retrohepatic vena cava have a low probability of survival. Death most commonly is caused by intraoperative exsanguination. Knowledge of the anatomy and exposure techniques for the five different segments of the intra-abdominal vena cava is very important to trauma surgeons. Although some wounds of the vena cava, especially those of the retrohepatic vena cava, are best left unexplored, most injuries inferior to this level can be exposed and repaired by lateral suture technique. Preservation of a lumen of at least 25% of normal is probably important in the suprarenal vena cava but is of no provable value inferior to the renal veins. No evidence supports the need to expose and repair vena caval wounds that have spontaneously stopped bleeding. Such wounds, especially in the retrohepatic area, may be managed expectantly provided that there is no strong suspicion of an associated injury to a major artery or hollow viscus.

Hipervolemia mais tríplice oclusão vascular no tratamento da lesão traumática da veia cava retro-hepática e veias hepáticas

BACKGROUND: Liver vascular isolation is essential for the treatment of the retrohepatic vena cava and hepatic veins. Triple vessel occlusion (TVO - occlusion of the portal triad, the inferior vena cava above the renal veins and within the pericardium) is the easiest isolation method for the surgeon. Unfortunately, this technique cannot be applied to hypovolemic and/or shock (cardiac arrest) patients as it compromises venous return. OBJECTIVES: Our objective is to demonstrate that in the above mentioned patients, establishing a previous hypervolemic state allows the safe use of TVO. METHODS: The method includes efficient injury tamponade with aggressive fluid replacement until normal blood volume is reached (resuscitation). Normal blood volume is recognized by a return of arterial blood pressure to normal levels, inferior vena cava filling and an increase in aortic wall tension. Following this procedure, hypervolemia is obtained by the rapid additional infusion of 1.500 to 2.000 ml of fluids. TVO in this situation does not alter the heart rhythm and maintains a clear operative field which is essential for hepatotomy, venorrhaphy and or venous ligation. RESULTS: Three patients were successfully operated.

Retrohepatic Vena Cava and Juxtahepatic Venous Injuries

The daunting mortality encountered with retrohepatic vena cava and juxtahepatic venous trauma is testimony to the difficulties inherent in their management. For a successful outcome, the operating surgeon must be able to rapidly identify the nature of the injury and tailor the choice of procedure accordingly. Atriocaval shunting, balloon shunting, sequential vascular clamping, and perihepatic packing are all methods of treatment with which the surgeon must be familiar. In this review, we present a case of this injury caused by a gunshot wound. This serves as a useful starting point for a discussion of the techniques available for addressing this injury.

Factors affecting mortality rates in patients with abdominal vascular injuries.

Major vessel injury is seen in 5% to 25% of patients admitted to hospitals with abdominal trauma, and this is the most common cause of death in these patients. Data on 470 patients with abdominal vascular injuries seen at a Level I trauma center were reviewed retrospectively. The overall mortality rate was 45%. The incidence of various types of trauma were blunt in 51 patients (11%), gunshot wounds in 329 patients (70%), shotgun wounds in 21 patients (4%), and stab wounds in 69 patients (15%). The three vessels with the highest mortality rates were aorta (at and proximal to the renals) (32 of 35 [91%]), hepatic veins and/or retrohepatic vena cava (36 of 41 [88%]), and portal vein (25 of 36 [69%]). The most significant risk factors (p < 0.001) for death were a trauma score of 9 or less, initial operating room (OR) systolic blood pressure (SBP) < 90 mm Hg, final OR core temperature < 34 degrees C, 10 or more blood transfusions in the first 24 hours, and an initial emergency department SBP < 70 mm Hg. Of 120 patients with an initial OR SBP < 70 mm Hg, 103 (86%) died. Of 29 patients with a good response to a prelaparotomy thoracotomy with thoracic aortic cross-clamping (SBP > 90 mm Hg within 5 minutes), 11 (38%) survived. Of the remaining 87 patients, only 6 (7%) survived (p = 0.01). Rapid control of bleeding sites (to keep blood transfusions to < 10 units) and urgent correction of hypothermia seem to be the main factors improving survival over which the surgeon has some control.

Surgical Management of Renal Cell Carcinoma with Vena Caval Extension

Retrohepatic vena cava surgery was performed in nine patients with renal cell carcinoma and with a propagation of the neoplastic thrombus into the inferior vena cava (IVC) up to the confluence with hepatic veins or to the right heart. Surgical treatment consisted of simultaneous radical nephrectomy and exploration of the retrohepatic vena cava with careful removal under direct vision of the thrombus, which was attached to the intima. In two patients cardiopulmonary bypass was used. All procedures were performed under IVC exclusion. Five patients are still alive from 2 up to 48 months after surgery. Surgical technique and postoperative management including vascular complications are discussed.

A new technique for resecting ‘unresectable’ liver tumors

Background/Purpose: Liver tumors that surround the three major hepatic veins traditionally have been considered unresectable. This report describes an extended atypical left hepatectomy technique for tumors around the major hepatic veins. Methods: Three children with tumors surrounding the 3 hepatic veins underwent intraoperative evaluation for extended atypical left hepatectomy. The left hepatic artery, left branch of the portal vein, and the 3 hepatic veins are occluded with vascular clamps. Perfusion of the remaining liver is through the right hepatic artery and portal vein into the retrohepatic vena cava via the retro hepatic veins. If the liver remains soft and does not become mottled, division of the 3 hepatic veins and resection of the tumor are carried out. Results: Extended atypical left hepatectomy was successful in 2 children. Bile leak occurred in 1 instance and healed spontaneously. Both patients had transiently elevated serum bilirubin and transaminase levels and an elevated prothrombin time for 2 weeks. Both survived after treatment with chemotherapy. In the third child the liver became tense and mottled, and the procedure was abandoned. Conclusions: Successful extended atypical left hepatectomy depends on the ability of the retro hepatic veins to adequately drain blood into the vena cava after interruption (clamping) of the main hepatic veins. If the liver becomes mottled and tense the procedure must be abandoned and the patient should be considered for hepatic transplantation. J Pediatr Surg 35:1294-1299. Copyright © 2000 by W.B. Saunders Company.

Specific vascular complications of orthotopic liver transplantation with preservation of the retrohepatic vena cava: review of 1361 cases.

The objective of this study was to describe the complications specifically related to orthotopic liver transplantation (OLT) with preservation of the inferior vena cava and to their therapeutic management. This preservation technique has considerably influenced the surgical phases of liver transplantation, increasing hepatectomy time and modifying the number of vascular anastomoses. Our retrospective multicentric study, based on data from 1361 adult patients that had undergone orthotopic liver transplantation with preservation of the inferior vena cava in France between 1991 and 1997, analyzed the concomitant surgical complications. Type of cavo-caval anastomosis performed (piggyback, end-to-side, or side-to-side), use of a temporary portacaval anastomosis, technique-related complications, and mortality, were investigated. Cavo-caval anastomosis was side-to-side in 50.6% of cases (n=689), piggyback in 42.7% (n=582), and end-to-side in 6.6% (n=90). In total, 882 temporary portacaval anastomosis were carried out. Fifty-five patients presented with one or more complications related to the preservation of the inferior vena cava technique; i.e., overall morbidity was 4.1% (55/1361). Overall mortality was 0.7% (10/1361). Mortality rate for patients who presented with surgical complication was 18%. A total of 64 complications were recorded: 57 (89%) were in the perioperative or immediate postoperative period and 7 (11%) were postoperative. These retrospective, descriptive results show significant advantages in favor of side-to-side anastomosis in terms of vascular complications. Certain factors should be evaluated specifically at pretransplant assessment to prevent certain serious complications; principally, these are anatomic factors of the recipient (inferior vena cava included in segment I, anatomic abnormalities of the inferior vena cava) and graft size. Depending on these factors, surgeons must be able to adapt the orthotopic liver transplantation, either before or during orthotopic liver transplantation, preferring the standard technique.

Anatomy of the common trunk of the middle and left hepatic veins: application to liver transplantation.

An anastomosis between the common trunk of the middle and left hepatic veins of the receiver and the cranial portion of the inferior vena cava of the donor is one of the techniques for restoration of hepato-caval continuity in orthotopic liver transplantation. This technique avoids dissection of the retrohepatic vena cava and total caval clamping. The aim of this study was to define the feasibility of this technique by a morphologic and biometric study of the common trunk of the middle and left hepatic veins on the basis of 64 injection-corrosion hepatic specimens and 21 fresh subjects. A common trunk for the middle and left hepatic veins was present in 54 of 64 cases (84%) with a length of 3 to 17 mm. The diameter of the new ostium constructed by section 0.5 cm proximal to the junction of the middle and left hepatic veins was 23.9 +/- 2.3 mm, which approximated to that of the vena cava where it traversed the diaphragm (24.4 +/- 2.0 mm). These findings confirmed that restoration of hepato-caval continuity by anastomosis between the common trunk of the middle and left hepatic veins of the receiver and the cranial portion of the vena cava of the graft is possible without incongruence. This study makes no assumptions about the hemodynamic effects associated with the smallest diameter of the true ostium of the common trunk at its opening into the inferior vena cava. In this study, the morphology of the common trunk was comparable to that observed by Nakamura. Further, we propose an anatomo-clinical classification allowing evaluation of the facility of vascular control of the common trunk in terms of the number and location of the collateral veins.

Budd-Chiari syndrome: shunt or transplant?

Background: Budd-Chiari syndrome is an uncommon disorder caused by obstruction to hepatic venous outflow, causing varying degrees of hepatic injury depending on the extent, severity, and acuity of the obstruction. Patients and Methods: We reviewed the indications for operative intervention and the results of treating 32 patients with Budd-Chiari syndrome seen at Toronto Hospital between 1968 and 1995. Results: Twenty-one patients underwent porto-systemic shunt (PSS) and 7 patients underwent liver transplantation (LT) as their initial operative management. Three patients who initially had PSS subsequently required LT. Patients with cirrhosis found on biopsy and preservation of hepatocellular function were treated with PSS and showed no difference in outcome when compared with patients without cirrhosis (P=0.35). Patients who were treated by PSS with retrohepatic vena caval compression, as shown by high caval gradients had outcomes similar to those for patients with low gradients (P=0.31). Using the Kaplan- Meier method, 5-year survival of PSS patients was 57%. Liver transplantation was used to manage patients with hepatic decompensation, as well as patients with vena caval occlusion or failed PSS. The 5-year Kaplan-Meier survival for LT was 67%. Conclusions: Both PSS and LT are effective options in the management of Budd-Chiari syndrome. Portosystemic shunt is the preferred initial approach even with cirrhosis or retrohepatic caval compression as long as there is preservation of liver function and a patent vena cava. Liver transplantation should be used as primary therapy for patients with irreversible hepatic decompensation or vena caval occlusion, and it can be an effective salvage procedure following failed PSS.

Infrahepatic Terminolateral Cavo–Cavostomy as a Rescue Technique in Complicated “Modified” Piggyback Liver Transplantation

Orthotopic liver transplantation is a well-known and widely applied codified procedure. Milestones of the standard technique are the use of the veno– venous bypass (1, 2), and the resection, en bloc with the liver, of the retrohepatic vena cava (3–5). Since its original description by Starzl (3–4), many modifications of the original technique have been suggested to reduce risks and time and to make the technique more flexible. Also, the graft caval implant has undergone gradual evolution through the introduction of variants that render the surgical procedure more adaptable toward problems. These techniques apply the dissection of the recipient liver from the vena cava during hepatectomy (6); then the graft implant may be performed preserving the recipient vena cava, according to the piggyback procedure (7, 8), anastomosing the donor’s suprahepatic vena cava and a “cuff” made out of the recipient’s suprahepatic veins, or, as described by some authors (9), using a side-to-side cavo–caval anastomosis after stitching the donor’s suprahepatic caval stumps. In both cases, the remnant of the donor’s infrahepatic vena cava must be ligated. Since 1992 we have used a modified piggyback technique, by performing an end-to-side cavo– caval anastomosis between the suprahepatic donor’s vena cava and the recipient’s vena cava, using the caudally enlarged hole of the common left and middle suprahepatic veins stump, after stitching the recipient’s right suprahepatic vein (10). Also by this technique, the remnant of the donor’s infrahepatic vena cava must be ligated. A drawback of these techniques may be either hepatic venous outflow obstruction because of stenosis or kinking of the caval anastomosis, or obstruction of the recipient’s inferior vena cava (11). We report a case of hepatic venous outflow obstruction at liver reperfusion because of kinking of the caval anastomosis. The stenosis was overcome performing an end-to-side cavo–caval anastomosis using the infrahepatic stump of the donor’s vena cava.

Total vascular exclusion of the liver during hepatic surgery. Selective use, extensive use, or abuse?

To review our experience with total vascular exclusion of the liver and to assess its role in hepatic resections. Retrospective survey. University hospital, a tertiary referring center for surgical liver diseases. A total of 722 patients who underwent liver resections from November 1, 1981, to March 31, 1996, of whom 19 (2.6%) required total vascular exclusion because of hepatic lesions closely adherent to or infiltrating the retrohepatic vena cava or centrally located in the liver, strictly in contact with the hepatic vein convergence. chi 2 Test for qualitative data and Student t test for categorical data. Of the 19 resections carried out under total vascular exclusion, 6 had tumoral infiltration of the retrohepatic vena cava: in 4 cases the venous wall was partially resected, while in the remaining 2 it was completely removed and replaced with a prosthetic graft. There were no operative deaths. Of the 722 resections, 227 were major hepatectomies: 74 (32.6%) were performed after ligation of the glissonian elements for the hemiliver to be removed, without clamping of the hepatic pedicle, and a further 36 (15.8%) were performed without any preliminary vascular control. A significant reduction in intraoperative blood transfusions was achieved despite the performance of more extended operations, regardless of the technique used. Total vascular exclusion is a useful tool in controlling blood inflow to the liver, but true need for it during liver resection is limited. Its performance requires a well-trained team familiar with problems regarding surgical access to the inferior vena cava and prolonged occlusion of the hepatic pedicle and the inferior vena cava.