Suprahepatic Vena Cava Research Articles

The role of median sternotomy in resections for large hepatocellular carcinomas

Background The aim of this study was to identify the role of median sternotomy in the hepatic resection of large hepatocellular carcinomas (HCCs). Methods From 1992 to 2002, 26 patients who underwent hepatectomy for large HCCs greater than 10 cm in diameter were divided into 2 groups according to the type of incision performed: with median sternotomy (10 patients) or without median sternotomy (16 patients). Results Median sternotomy was performed for 3 patients with tumor thrombus extending into the right atrium and for 7 patients with inadequate exposure of the hepatic veins and suprahepatic vena cava. In these 7 cases, the tumors were located mainly at the upper part of the right lobe in 4 patients and the upper part of the left lobe in 3 patients. Median sternotomy was performed in 6 of 7 patients whose tumor was located in segments 2, 4, 7, and 8, and was greater than 16 cm. No significant differences were found in the intraoperative parameters of blood transfusion, ischemic time, area of the cut surface, and operation time. Conclusions Median sternotomy may be suitable for use as an approach for large HCCs greater than 16 cm, which are located at the upper part of the liver.

Ascites after liver transplantation and inferior vena cava reconstruction in the piggyback technique

we have used the piggyback technique byperforming an end-to-side cavocaval anastomosis betweenthe suprahepatic donor vena cava and the recipient venacava, as described by Starzl. The donor suprahepatic venacava is anastomosed to the vascular cuff formed by combin-ing the lumina of the three suprahepatic veins of therecipient.

Extracorporeal circulation for repair of suprahepatic vena cava stenosis after liver transplantation

Transplant InternationalVolume 15, Issue 11 p. 589-590 Free to Read Extracorporeal circulation for repair of suprahepatic vena cava stenosis after liver transplantation Florian Iberer, Corresponding Author Florian Iberer Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaE-mail: florian.iberer@kunigraz.ac.at Tel.: +34-316-38583932 Fax: +43-316-3854446Search for more papers by this authorBarbara Grasser, Barbara Grasser Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaSearch for more papers by this authorSilvia Schaffellner, Silvia Schaffellner Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaSearch for more papers by this authorDaniela Kniepeiss, Daniela Kniepeiss Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaSearch for more papers by this authorVanessa Stadlbauer, Vanessa Stadlbauer Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaSearch for more papers by this authorKarl-Heinz Tscheliessnigg, Karl-Heinz Tscheliessnigg Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaSearch for more papers by this author Florian Iberer, Corresponding Author Florian Iberer Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaE-mail: florian.iberer@kunigraz.ac.at Tel.: +34-316-38583932 Fax: +43-316-3854446Search for more papers by this authorBarbara Grasser, Barbara Grasser Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaSearch for more papers by this authorSilvia Schaffellner, Silvia Schaffellner Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaSearch for more papers by this authorDaniela Kniepeiss, Daniela Kniepeiss Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaSearch for more papers by this authorVanessa Stadlbauer, Vanessa Stadlbauer Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaSearch for more papers by this authorKarl-Heinz Tscheliessnigg, Karl-Heinz Tscheliessnigg Department of Transplantation, Division of Surgery, University Hospital and Medical School, Karl-Franzens University of Graz, Auenbruggerplatz 29, 8036 Graz, AustriaSearch for more papers by this author First published: 11 March 2005 https://doi.org/10.1111/j.1432-2277.2002.tb00114.xCitations: 2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume15, Issue11November 2002Pages 589-590 RelatedInformation

Continuing Experience with Liver Resection and Vena Cava Reconstruction using Cardiopulmonary Bypass and Hypothermic Circulatory Arrest

When the suprahepatic vena cava or the hepatic vein confluence with the inferior vena cava (IVC) is obscured by tumor or a clot in the IVC extends above the liver, cross-clamping the IVC during liver or retroperitoneal resection is hazardous. This report describes a 10-year experience with ten patients who had liver (seven) or retroperitoneal (three) resections with vena cava reconstruction using cardiopulmonary bypass and hypothermic circulatory arrest. There were no perioperative deaths. Morbidity consisted of prolonged bile leak (one), pulmonary embolism (one), and stroke (one). Control of the liver was secured in six of seven patients who had a liver resection. There were three significant advantages to this technique. First, the median sternotomy provided superior exposure to the suprahepatic IVC. Second, the bypass technique avoided the risks of hemodynamic instability and prevented air embolism and sudden uncontrolled hemorrhage incurred by resection or IVC cross-clamping. Third, hypothermia provided a method of protection for residual liver function especially in the face of chronic liver disease induced by infection or chemotherapy.

Elevated intrahepatic pressures and decreased hepatic tissue blood flow prevent gas embolus during limited laparoscopic liver resections.

As new techniques are emerging for laparoscopic liver resections, concerns have been raised about the development of gas embolus related to the CO(2) pneumoperitoneum. We hypothesized that elevated intrahepatic vascular pressures and decreased hepatic tissue blood flow (LQB) would prevent gas embolus during laparoscopic liver resections under conventional pneumoperitoneum. Intrahepatic vascular pressures and LQB were measured in nine pigs with varying CO(2) pneumoperitoneum. Gas embolus was determined after hepatic incision by monitoring pulmonary arterial pressure (PAP), hepatic venous PCO(2), systemic blood pressure (SBP), and suprahepatic vena cava ultrasound. As the pneumoperitoneum was increased from 0 to 15 mmHg, intrahepatic vascular pressures increased significantly (p < 0.05), while LQB decreased significantly (p < 0.05). A 2.0-cm hepatic incision at 4, 8, 15, and 20mmHg produced no ultrasound evidence of gas embolus and no changes in PAP, SBP, or hepatic venous PCO(2) (p = NS). These data suggest that the risk of significant embolus under conventional pneumoperitoneum is minimal during laparoscopic liver resections.

SIMPLIFIED TECHNIQUE OF ORTHOTOPIC LIVER TRANSPLANTATION IN PIGS1

Pig models have become common in transplantation immunological research. However, in pigs, clamping of the venous splanchnic system during orthotopic liver transplantation (OLT) is responsible for high morbidity and mortality rates; therefore, the use of venovenous bypass (VVB) is advocated. Because venous bypass can also cause specific complications, a simplified method for OLT in pigs has been developed and evaluated in terms of morbidity and mortality. Twenty-three OLTs were performed between pairs of inbred miniature swine. Donor and recipient pairs (weighing 20-35 kg) were selected at 3-6 months of age. In the donor, the portal vein, infrahepatic vena cava, and suprahepatic vena cava were dissected, whereas the hepatic artery was preserved in continuity with the coeliac trunk and the abdominal aorta up to the iliac bifurcation. In situ cold perfusion was then performed. The recipient was prepared simultaneously by another surgical team. After total hepatectomy and complete portal and caval clamping, the suprahepatic vena cava and portal vein were sutured; VVB was not used. After completion of both venous sutures, the liver graft was reperfused. The infrahepatic vena cava was then anastomosed and unclamped. The donor aorta conduit was implanted end-to-side to the recipient infrarenal aorta, and the biliary reconstruction consisted of a cholecystojejunostomy with a Roux-Y loop. Twenty of 23 (87%) animals survived more than 1 week (7-483 days). The mean anhepatic time was 29.6+/-4.12 min. Although severe hypotension was noted during the anhepatic phase, the hemodynamic status rapidly recovered and stabilized after graft reperfusion. Simplified technique without VVB is appropriate for successfully achieving OLT in pigs.

Vascular control for resection of suprahepatic intracaval Wilms' tumor: Technical considerations

The surgical resection of Wilms' tumor can be complicated by tumor thrombus extension into the inferior vena cava. In cases of suprahepatic Wilms' tumor thrombus that may extend into the right atrium, a median sternotomy and cardiopulmonary bypass (CPB) are used to facilitate tumor resection. However, if the tumor can be localized and controlled below the atrium, resection without the use of cardiopulmonary bypass may limit morbidity. The authors describe a novel approach to tumor thrombectomy for a Wilms' tumor extending to the suprahepatic vena cava without the use of CPB. The authors used transesophageal echocardiography to localize the tumor thrombus and detect any tumor or air embolization and a minimal lower sternotomy to obtain intrapericardial control of the inferior vena cava. This technique may be useful in selected cases of Wilms' tumor as an alternative to median sternotomy and use of cardiopulmonary bypass. J Pediatr Surg 35:1836-1837. Copyright © 2000 by W.B. Saunders Company.

Cervical heterotopic arterialized liver transplantation in the mouse.

Orthotopic liver transplantation in the mouse is an extremely demanding procedure. Since the mouse, however, would be a good model for the study of various transplantation-related problems, we designed a new surgical technique for cervical heterotopic arterialized reduced-size liver transplantation. Eighty percent hepatectomy was performed ex vivo and the remaining liver segment was transplanted to the neck of the recipient. The donor aorta was anastomosed to the right common carotid artery, the portal vein to the distal right external jugular vein, and the donor suprahepatic vena cava to the proximal right external jugular vein using a cuff technique. The bile duct was brought out as a cutaneous stoma. This relatively simple technique was performed in 22 BALB/C mice and associated with a high success rate: three mice died within 5 days due to surgical complications. All grafts in survivors were structurally normal until postoperative day 7 and began to show histological signs of atrophy around day 14. It is concluded that this technique may be useful for preservation, regeneration and reperfusion studies, and factors responsible for the maintenance of hepatocyte integrity in heterotopic liver transplantation.

Budd-Chiari Syndrome with Spleno-Mesenteric-Portal Thrombosis: Treatment with Extended TIPS

JVIR 2000; 11:781–784 BUDD-CHIARI syndrome (BCS) is defined as a hepatic venous obstruction at the level of the suprahepatic inferior vena cava or of the small or large hepatic veins causing liver failure and portal hypertension (1). There is a wide range of different clinical courses depending on the acuity and extent of venous occlusion. Acute venous thrombosis may be successfully recanalized with systemic lytic therapy (2). Most often, in particular if the diagnosis is delayed or the disease has an insidious course, surgery or interventional radiology will be required to treat portal hypertension and progressive liver failure either by creation of a surgical or transjugular portosystemic shunt (TIPS) or by liver transplantation. TIPS can be a live-saving procedure in patients with BCS and fulminant liver failure and may be used as a bridge to liver transplantation (3,4). Associated portal, mesenteric, or splenic thrombosis has been reported to occur in up to 25% of patients with BCS. This subgroup has a much worse prognosis as liver transplantation or shunt surgery are usually no more feasible (5). We report the interventional radiological management of a patient with BCS complicated by chronic thrombosis of the splenic vein, superior mesenteric vein (SMV), and portal vein (PV), with combined transhepatic recanalization of the mesenteric and PVs and transjugular creation of a TIPS to the suprahepatic vena cava.

Caspase inhibition protects from liver injury following ischemia and reperfusion in rats.

Normothermic ischemia and reperfusion of the liver results in microcirculatory failure followed by necrosis and cell death. Recently, another type of cell death, apoptosis or programmed cell death, was found to be activated during the early phase of reperfusion after liver ischemia. Caspases are cysteine proteinases specifically involved in the initiation and execution phases of apoptosis. The aim of this study was to demonstrate that inhibition of apoptosis by a specific inhibitor of caspases might protect the liver against ischemia/reperfusion injury. Rats were divided into three groups: group 1, control, PBS administration; group 2, Z-Asp-cmk (Z-Asp-2,6-dichlorobenzoyl-oxymethylketone) treatment; group 3, sham-operated control animals. Z-Asp-cmk (0.5 mg Z-Asp-cmk dissolved in 300 microl PBS solution containing 1% DMSO) was injected intravenously, 2 min prior to induction of 120 min ischemia. Survival rates were compared and serum activities of aspartate aminotransferases and alanine aminotransferases were assessed in the blood collected from the suprahepatic vena cava. Histology of the liver was assessed 6 h after the end of ischemia. Apoptosis was detected by the terminal deoxynucleotidyl transferase-mediated dUTP-FITC nick end-labeling method (TUNEL method) and by electrophoresis for analysis of DNA fragmentation. Caspase activity was determined by measuring hydrolysis of the CPP32-like substrate Ac-DEVD-pNA and absorption of paranitroaniline. Z-Asp-cmk treatment significantly increased 7-day survival (95%) compared with that in nontreated rats (30%, P < 0.001). Serum activities of aminotransferases and the extent of liver congestion and necrosis were significantly (P < 0.001) decreased after treatment with Z-Asp-cmk. TUNEL-positive cells were detected 3-6 h after reperfusion in the control group. In Z-Asp-cmk pretreated rats, a dramatic decrease in the number of TUNEL-positive cells was observed. Analysis of DNA fragmentation of freshly isolated hepatocytes confirmed these results. Caspase activity was increased 3-6 h after reperfusion in the control group, but significantly (P < 0.001) decreased after treatment with Z-Asp-cmk. These findings demonstrate that liver injury following ischemia and reperfusion can be prevented by inhibition of caspases. Caspase inhibitors may have important implications for therapy in liver disease and after liver transplantation.

Extended Subcostal Hinge Incision for Right Hepatic Lobectomy

The safe performance of a right hepatic lobectomy requires adequate exposure of the hepatic veins and of the suprahepatic vena cava. An extended subcostal or midline incision is commonly used to provide exposure for this operation. The technique for an extended subcostal incision that uses the natural hinge mechanism of the rib cage to provide exposure to the right upper quadrant is described. This approach provides adequate exposure during a difficult hepatectomy, avoiding the need for a thoracotomy or sternotomy.

Allograft transduction of IL-10 prolongs survival following orthotopic liver transplantation.

Interleukin-10 (IL-10) is an ideal candidate cytokine for suppressing the alloimmune response in transplantation. To determine whether genetic modulation of the hepatic graft with IL-10 could prolong survival following orthotopic liver transplantation, we constructed a replication-deficient adenovirus vector expressing human IL-10 (AdCMVhIL-10). Intraportal injection of this vector into a donor rat 24-48 h before grafting resulted in efficient release of IL-10 into the circulation of a recipient rat after transplantation. Moreover, levels of hIL-10 from the suprahepatic vena cava were significantly (1.48-fold) higher than those from the infrahepatic vena cava (P = 0.013), indicating local IL-10 production within the transduced hepatic graft. AdCMVhIL-10 induced a prolongation of median survival to more than 87 days, with two of five transduced grafts showing more than 100 days of ongoing survival, when compared with 11 days for grafts transduced with a control adenovirus vector carrying the E. coli beta-galactosidase gene (P = 0.0021) and 11 days for untreated grafts (P = 0.0021). Pathological findings occurring in the AdCMVhIL-10-transduced hepatic grafts revealed no evidence of progressive rejection reaction resulting in graft failure. These results demonstrate that hepatic grafts modulated by IL-10 gene transfer make local and effective immunosuppression feasible in the transplantation setting.

Budd-Chiari syndrome: blocked veins, open mind

See article on page 568 The article by Fisher et al (see page 568) on the various techniques that may be used in the management of Budd-Chiari syndrome is timely,...

Usefulness of cardiopulmonary bypass in reconstruction of inferior vena cava occupied by renal cell carcinoma tumor thrombus.

Aggressive surgical treatment in renal cell carcinoma is still controversial. The aim of this paper is to assess inferior vena caval (IVC) reconstruction for suprahepatic vena caval renal cell carcinoma (RCC) tumor thrombus. Twelve patients with suprahepatic vena caval thrombus from renal cell carcinoma who underwent surgical repair with cardiopulmonary bypass were evaluated. The vena caval defect was reconstructed by direct suture, patch repair, or graft replacement. Of 12 patients undergoing partial cardiopulmonary bypass, tumor thrombus extended to the junction of the hepatic vein in three patients and to the right atrium in one. Tumor thrombus was removed manually or with balloon catheter. Tumor thrombus in the right atrium was removed during electrical ventricular fibrillation. Repair of the IVC was performed by direct suture of the IVC wall in two patients, patch repair with expanded polytetrafluoroethylene (EPTFE) graft in seven, and graft replacement with an EPTFE graft in three. There were no operative deaths and the only postoperative complication was one patient death from pulmonary emboli. The four patients with nonlocalized disease died within 2 years, but four patients lived for more than 3 years postoperatively. Survival was 37.5% at 3 years and 18.8% at 5 years by the Kaplan-Meier's method. (1) Partial cardiopulmonary bypass is useful for the control of bleeding when tumor thrombus in the IVC extends to the junction of the hepatic vein. (2) Nephrectomy with tumor thrombectomy of the IVC is valuable, and long-term survival is possible in patients without distant metastases or regional lymph node metastases.

Improvement of Normothermic Rat Liver Ischemia/Reperfusion by Muramyl Dipeptide

Normothermic ischemia and reperfusion (I/R) of the liver remains a major problem after liver surgery and transplantation. Activation of Kupffer cells (KCs) after normothermic I/R is responsible for a massive release of various monokines such as tumor necrosis factor α (TNF-α) and a decrease in phagocytic activity. Muramyl dipeptide (MDP) is an immunostimulant that increases phagocytic activity of KCs. The aim of this study was to demonstrate that MDP pretreatment might protect the liver against I/R injury by a modification of KC functions. Rats were divided into three groups: group 1, control, Ringer's lactate administration; group 2, MDP (N-acetyl-muramyl-d-alanyl-d-isoglutamine) treatment; group 3, sham-operated control animals. MDP (500 μg/250 g) was injected intravenously 5 min before the induction of 90 min ischemia. Survival rates were compared and serum activities of TNF-α, aspartate aminotransferase, and alanine aminotransferase were assessed in the blood collected from the suprahepatic vena cava. Histology of the liver and KC activity were assessed 6 and 9 h after the end of ischemia, respectively. MDP treatment significantly increased 7-day survival (86.6%) compared with nontreated rats (40%,P< 0.001). Serum activities of TNF-α and aminotransferases were significantly decreased after MDP treatment, whereas phagocytic capacity of KCs was partially restored. The extent of liver necrosis was decreased after MDP administration. A significant difference was observed for other histological parameters studied, except for steatosis. Our findings have demonstrated that MDP is able to protect the liver from ischemic insult by modulation of KC activity (TNF-α release and phagocytic capacity). Control of macrophage activity may offer a new strategy to reduce ischemic injury of the liver.

Liver resection using total vascular exclusion

Background: Total vascular exclusion (TVE) is a technique of liver resection that includes controlling both the suprahepatic and infrahepatic vena cava in addition to portal inflow at the time of parenchymal transection. We report a series of 61 liver resections in 60 patients using this technique. Methods: A retrospective review of 61 procedures in 60 patients using TVE between 1990 and 1997 was carried out. No patient had cirrhosis. Parameters analyzed included age, gender, diagnosis, procedure, operative time, clamp time, intraoperative transfusion requirements, postoperative laboratory studies, length of stay (intensive care unit, ward), mortality, and morbidity. Results: TVE was sustained hemodynamically in all patients. The mean age of the 34 men and 27 women was 56 years (± 15 years); 21% were older than 70 years. Eleven percent of the patients had benign lesions; 70% of the malignant tumors were metastatic. Seventy-five percent of the procedures were major or extended lobectomies. The mean operative and clamp times were 330 ± 83 and 39 ± 13.2 minutes, respectively; 68% had clamp times of <45 minutes. The mean intraoperative red blood cell units was 1.45 ± 1.93, with a range of 0 to 8 units; 48% required no transfusion and 80% received 2 units or less. There was 1 perioperative death for a mortality rate of 1.6%. The morbidity rate was 36%, which included 4 patients with postoperative liver dysfunction. Complications were not associated with transfusion but with clamp times exceeding 45 minutes. Liver dysfunction occurred with clamp times more than 60 minutes, particularly if the remaining liver parenchyma was histologically abnormal or the remnant was small. Conclusions: TVE is hemodynamically safe, even in patients older than 70 years. Blood loss during parenchymal transection is minimal; mortality and morbidity are low. The optimal clamp time is less than 45 minutes. Liver dysfunction is associated with clamp times exceeding 1 hour, particularly if the remaining parenchyma is abnormal or small. (Surgery 1998;124:807-15.)

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.

Rationale and technical constraints of a tertiary liver transplantation

Because of the current shortage of donor organs, the routine performance of tertiary liver transplantation (LT) may be questioned. In this study, the indications of tertiary LT are discussed, paying particular attention to intraoperative technique. Of 501 LTs performed from 1986 to 1995, eight (1.6%) were tertiary LTs. Three patients underwent an emergent third LT because of associated hepatic artery and portal vein thromboses (n = 2) or hyperacute rejection (n = 1). Five patients had an elective third LT for ischemic cholangitis (n = 4) or chronic rejection (n = 1). The 3 patients who underwent retransplantation emergently died early from multiple-organ failure. Because of previous surgery and subsequent technical difficulties, the third LT in the remaining 5 patients required unroutine surgical procedures including the following: intrapericardial control of the suprahepatic vena cava (n = 1), "en bloc" clamping of both the infrahepatic vena cava and the hepatic pedicle (n = 1), arterial reconstruction onto the aorta via an aortoiliac conduit (n = 5), and aortic resection with aortoaortic prosthetic reconstruction (n = 1). Of these 5 patients, 4 required reoperation because of bowel perforation (n = 5) or intraperitoneal bleeding (n = 1). The 5 patients (62%) who were regrafted electively are alive and well after a median follow-up of 45 months. A third LT can be reasonably offered to selected young recipients if performed electively. Tertiary LT may require unroutine surgical procedures and may lead to severe morbidity. (Liver Transpl Surg 1997 Nov;3(6):624-7)

Rationale and technical constraints of a tertiary liver transplantation

Because of the current shortage of donor organs, the routine performance of tertiary liver transplantation (LT) may be questioned. In this study, the indications of tertiary LT are discussed, paying particular attention to intraoperative technique. Of 501 LTs performed from 1986 to 1995, eight (1.6%) were tertiary LTs. Three patients underwent an emergent third LT because of associated hepatic artery and portal vein thromboses (n = 2) or hyperacute rejection (n = 1). Five patients had an elective third LT for ischemic cholangitis (n = 4) or chronic rejection (n = 1). The 3 patients who underwent retransplantation emergently died early from multiple-organ failure. Because of previous surgery and subsequent technical difficulties, the third LT in the remaining 5 patients required unroutine surgical procedures including the following: intrapericardial control of the suprahepatic vena cava (n = 1), "en bloc" clamping of both the infrahepatic vena cava and the hepatic pedicle (n = 1), arterial reconstruction onto the aorta via an aortoiliac conduit (n = 5), and aortic resection with aortoaortic prosthetic reconstruction (n = 1). Of these 5 patients, 4 required reoperation because of bowel perforation (n = 5) or intraperitoneal bleeding (n = 1). The 5 patients (62%) who were regrafted electively are alive and well after a median follow-up of 45 months. A third LT can be reasonably offered to selected young recipients if performed electively. Tertiary LT may require unroutine surgical procedures and may lead to severe morbidity.

In situ neural isolation of the entire canine upper gut: Effects on fasting and fed motility patterns

Background. Multiorgan upper gut transplantation is becoming clinically feasible; however, the effects of multivisceral transplantations on gastrointestinal motility are unknown. Our aim was to determine the neural and hormonal mechanisms controlling motility patterns after complete extrinsic denervation of the upper gut as a model of multivisceral upper gut autotransplantation. Methods. Seven dogs successfully underwent in situ neural isolation of the stomach, entire small intestine, proximal colon, liver, and pancreas by transecting all connections (distal esophagus, midcolon, all nerves, lymphatics) to this multivisceral complex except the celiac artery, superior mesenteric artery, and the suprahepatic and infrahepatic vena cava; these vessels were meticulously stripped of adventitia under optical magnification. Blood flow was not disrupted to prevent confounding effects of ischemia-reperfusion injury. After 1- to 2-week recovery, myoelectric and manometric recordings of stomach and myoelectric recordings of small bowel were obtained from conscious animals. Results. During fasting the characteristic cycling migrating motor complex (MMC) was observed in the stomach and small intestine. The gastric component of the MMC was absent in one of the seven dogs. Regular cycling of the MMC during fasting, however, was intermittently disrupted and replaced by a noncyclic pattern of intermittent contractions in two of seven dogs 43% of the recording time. A small meal (50 gm liver) did not abolish the MMC as occurs in normal dogs; in contrast, a large meal (500 gm liver) did abolish the MMC. Conclusions. Extrinsic innervation to the upper gut modulates but is not requisite for interdigestive and postprandial motility of the stomach. Because relatively normal global motility patterns are preserved, multivisceral upper gut transplantation should be a viable option in selected patients.