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Ma L, Peng C, Yang L, Zhu X, Fan H, Yang J, Wang H, Luo Y. Grading portal vein stenosis following partial hepatectomy by high-frequency ultrasonography: an in vivo study of rats. Diagn Interv Radiol 2025; 31:68-74. [PMID: 39582211 PMCID: PMC11880861 DOI: 10.4274/dir.2024.242912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 09/29/2024] [Indexed: 11/26/2024]
Abstract
PURPOSE To evaluate the diagnostic value of ultrasound in grading portal vein stenosis (PVS) in a rat model of 70% partial hepatectomy (PH). METHODS A total of 96 Sprague-Dawley rats were randomly divided into a PH group and PVS groups with mild, moderate, and severe PVS following PH. Hemodynamic parameters were measured using high-frequency ultrasound (5-12 MHz high-frequency linear transducer), including pre-stenotic, stenotic, and post-stenotic portal vein diameters (PVDpre, PVDs, PVDpost); pre-stenotic and stenotic portal vein velocity (PVVpre, PVVs); hepatic artery peak systolic velocity (PSV); end-diastolic velocity; and resistive index. The portal vein diameter ratio (PVDR) and portal vein velocity ratio (PVVR) were calculated using the following formulas: PVDR=PVDpre/PVDs and PVVR=PVVs/PVVpre. The value of these parameters in grading PVS was assessed. RESULTS Portal vein hemodynamics showed gradient changes as PVS aggravated. For identifying >50% PVS, PVDs and PVDR were the best parameters, with areas under the curve (AUC) of 0.85 and 0.86, respectively. For identifying >65% PVS, PVDs, PVDR, and PVVR were relatively better, with AUCs of 0.94, 0.85, and 0.88, respectively. The AUC of hepatic artery PSV for identifying >65% PVS was 0.733. CONCLUSION High-frequency ultrasonography can be used to grade PVS in rats, with PVDs, PVDR, and PVVR being particularly useful. Hepatic artery PSV may help in predicting >65% PVS. These findings provide valuable information for PVS rat model research and offer an experimental basis for further studies on PVS evaluation in living-donor liver transplantation (LDLT). CLINICAL SIGNIFICANCE Ultrasonography serves as a first-line technology for diagnosing PVS following LDLT. However, the grading criteria for PVS severity remain unclear. Investigating the use of ultrasonic hemodynamics in the early diagnosis of PVS and grading stenosis severity is important for early postoperative intervention and improving recipient survival rates.
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Affiliation(s)
- Lin Ma
- West China Hospital of Sichuan University, Department of Ultrasound, Sichuan, China
- West China Tian Fu Hospital, Sichuan University, Department of Ultrasound, Sichuan, China
| | - Chihan Peng
- West China Hospital of Sichuan University, Department of Ultrasound, Sichuan, China
| | - Lulu Yang
- West China Hospital of Sichuan University, Department of Ultrasound, Sichuan, China
| | - Xiaoxia Zhu
- West China Hospital of Sichuan University, Department of Ultrasound, Sichuan, China
| | - Hongxia Fan
- West China Hospital of Sichuan University, Department of Ultrasound, Sichuan, China
| | - Jiali Yang
- West China Hospital of Sichuan University, Department of Ultrasound, Sichuan, China
| | - Hong Wang
- West China Hospital of Sichuan University, Department of Ultrasound, Sichuan, China
| | - Yan Luo
- West China Hospital of Sichuan University, Department of Ultrasound, Sichuan, China
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Shang ZX, Yu QJ, Luo FZ, Zhuang L, Zheng SS, Yang Z. Split liver transplantation with complicated portal vein variations in graft. Hepatobiliary Pancreat Dis Int 2024; 23:658-660. [PMID: 37599132 DOI: 10.1016/j.hbpd.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/01/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Zhao-Xin Shang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China; Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan Hangzhou Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou 310015, China
| | - Qi-Jian Yu
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China; Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan Hangzhou Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou 310015, China
| | - Fang-Zhou Luo
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Li Zhuang
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan Hangzhou Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou 310015, China
| | - Shu-Sen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan Hangzhou Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou 310015, China
| | - Zhe Yang
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan Hangzhou Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou 310015, China.
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3
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Qian Y, Zhang W, Wang W, Li Z, Shao Y, Gao S, Wu J, Yu J, Zhang M, Shen Y, Bai X, Liang T. Risk factors for post-operative portal vein stenosis in pediatric liver transplantation: a single center case-control study. Pediatr Surg Int 2024; 40:113. [PMID: 38668784 DOI: 10.1007/s00383-024-05690-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2024] [Indexed: 12/14/2024]
Abstract
PURPOSE The incidence of post-transplant poral vein stenosis (PVS) is higher in pediatric liver transplantation, probably resulting from various portal vein (PV) reconstruction methods or other factors. METHODS 332 patients less than 12 years old when receiving liver transplantation (LT) were enrolled in this research. Portal vein reconstruction methods include anastomosis to the left side of the recipient PV trunk (type 1, n = 170), to the recipient left and right PV branch patch (type 2, n = 79), using vein graft interposition (type 3, n = 32), or end-to-end PV anastomosis (type 4, n = 50). The incidence of PVS was analyzed in terms to different PV reconstruction methods and other possible risk factors. RESULTS PVS occurred in 35 (10.5%) patients. Of the 32 patients using vein graft, 20 patients received a cryopreserved vein graft, 11 (55%) developed PVS, while the remaining 12 patients received a fresh iliac vein for PV interposition and none of them developed PVS. 9 patients whose liver donor was under 12 years old developed PVS, with an incidence of 18.8%. CONCLUSION Cryopreserved vein graft interposition and a liver donor under 12 are independent risk factors for PVS in pediatric LT.
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Affiliation(s)
- Yigang Qian
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weili Wang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhiwei Li
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yi Shao
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian Wu
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Yu
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Min Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yan Shen
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Liver Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Key Lab of Combined Multi-organ Transplantation of the Ministry of Health, the First Affiliated Hospital, Zhejiang University School of Medicine, 79# Qinchun Road, Hangzhou, China.
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4
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Siddiqui A, Faraoni D, Williams RJ, Eytan D, Levin D, Mazwi M, Ng VL, Sayed BA, Laussen P, Steinberg BE. Development and validation of a multivariable prediction model in pediatric liver transplant patients for predicting intensive care unit length of stay. Paediatr Anaesth 2023; 33:938-945. [PMID: 37555370 DOI: 10.1111/pan.14736] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Liver transplantation is the life-saving treatment for many end-stage pediatric liver diseases. The perioperative course, including surgical and anesthetic factors, have an important influence on the trajectory of this high-risk population. Given the complexity and variability of the immediate postoperative course, there would be utility in identifying risk factors that allow prediction of adverse outcomes and intensive care unit trajectories. AIMS The aim of this study was to develop and validate a risk prediction model of prolonged intensive care unit length of stay in the pediatric liver transplant population. METHODS This is a retrospective analysis of consecutive pediatric isolated liver transplant recipients at a single institution between April 1, 2013 and April 30, 2020. All patients under the age of 18 years receiving a liver transplant were included in the study (n = 186). The primary outcome was intensive care unit length of stay greater than 7 days. RESULTS Recipient and donor characteristics were used to develop a multivariable logistic regression model. A total of 186 patients were included in the study. Using multivariable logistic regression, we found that age < 12 months (odds ratio 4.02, 95% confidence interval 1.20-13.51, p = .024), metabolic or cholestatic disease (odds ratio 2.66, 95% confidence interval 1.01-7.07, p = .049), 30-day pretransplant hospital admission (odds ratio 8.59, 95% confidence interval 2.27-32.54, p = .002), intraoperative red blood cells transfusion >40 mL/kg (odds ratio 3.32, 95% confidence interval 1.12-9.81, p = .030), posttransplant return to the operating room (odds ratio 11.45, 95% confidence interval 3.04-43.16, p = .004), and major postoperative respiratory event (odds ratio 32.14, 95% confidence interval 3.00-343.90, p < .001) were associated with prolonged intensive care unit length of stay. The model demonstrates a good discriminative ability with an area under the receiver operative curve of 0.888 (95% confidence interval, 0.824-0.951). CONCLUSIONS We develop and validate a model to predict prolonged intensive care unit length of stay in pediatric liver transplant patients using risk factors from all phases of the perioperative period.
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Affiliation(s)
- Asad Siddiqui
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
| | - David Faraoni
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - R J Williams
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Danny Eytan
- Department of Critical Care Medicine, Rambam Medical Centre, Haifa, Israel
| | - David Levin
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
| | - Mjaye Mazwi
- University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Vicky L Ng
- University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada
| | - Blayne A Sayed
- University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
- Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Canada
| | - Peter Laussen
- Department of Critical Care Medicine, Boston Children's Hospital, Boston, USA
| | - Benjamin E Steinberg
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
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5
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Semash KO, Dzhanbekov TA, Akbarov MM. Vascular complications after liver transplantation: contemporary approaches to detection and treatment. A literature review. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2023; 25:46-72. [DOI: 10.15825/1995-1191-2023-4-46-72] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Vascular complications (VCs) after liver transplantation (LT) are rare but are one of the most dreaded conditions that can potentially lead to graft loss and recipient death. This paper has analyzed the international experience in the early diagnosis of various VCs that can develop following LT, as well as the optimal timing and methods of treatment of these complications.
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Affiliation(s)
- K. O. Semash
- Republican Specialized Scientific and Practical Medical Center for Surgery; Tashkent Medical Academy
| | - T. A. Dzhanbekov
- Republican Specialized Scientific and Practical Medical Center for Surgery; Tashkent Medical Academy
| | - M. M. Akbarov
- Republican Specialized Scientific and Practical Medical Center for Surgery; Tashkent Medical Academy
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6
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Kirchner VA, O'Farrell B, Imber C, McCormack L, Northup PG, Song GW, Spiro M, Raptis DA, Durand F. What is the optimal management of thromboprophylaxis after liver transplantation regarding prevention of bleeding, hepatic artery, or portal vein thrombosis? A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14629. [PMID: 35240723 PMCID: PMC10078564 DOI: 10.1111/ctr.14629] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/13/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND A key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review investigated the optimal management of thromboprophylaxis after LT regarding portal vein thrombosis (PVT) or hepatic artery thrombosis (HAT) and prevention of bleeding. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Seven databases were used to conduct extensive literature searches focusing on the use of anticoagulation in LT and its impact on the following outcomes: PVT, HAT, and bleeding (CRD42021244288). RESULTS Of the 2478 articles/abstracts screened, 16 studies were included in the final review. All articles were critically appraised by a panel of independent reviewers. There was wide variation regarding the anticoagulation protocols used. Thromboprophylaxis with therapeutic doses of heparin/Vitamin K antagonist combination did not decrease the risk of de novo or the recurrence of PVT but was associated with an increased risk of bleeding in some studies. Only the use of aspirin resulted in a small but significant decrease in the incidence of HAT post-LT, yet it did not increase the risk of bleeding. CONCLUSIONS Based on existing data and expert opinion, thromboprophylaxis at therapeutic or prophylactic dose is not recommended for prevention of de novo PVT following LT in patients not at high risk. Aspirin should be considered as the standard of care following LT to prevent HAT. Thromboprophylaxis should be strongly considered in recipients at risk of HAT and PVT following LT.
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Affiliation(s)
- Varvara A Kirchner
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, USA.,Department of Surgery, Division of Abdominal Transplantation, Stanford University, Stanford, USA
| | | | - Charles Imber
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Lucas McCormack
- Liver Surgery and Transplantation Unit, Department of Surgery, Hospital Aleman, Buenos Aires, Argentina
| | - Patrick G Northup
- Division of Gastroenterology, Department of Medicine, University of Virginia Health System, Charlottesville, USA
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri A Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - François Durand
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, France.,University of Paris, Paris, France.,INSER M U1149, Paris, France
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- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, USA
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7
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Badawy A, Brunner SM, Knoppke B, Völkl M, Junger H, Loss M, Sinner B, Huf V, Grothues D, Melter M, Schlitt HJ. Predictors of portal vein complications after pediatric liver transplantation: A German center experience. Pediatr Transplant 2022; 26:e14298. [PMID: 35460136 DOI: 10.1111/petr.14298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/03/2022] [Accepted: 04/09/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Portal vein complications (PVCs) after pediatric liver transplantation (LT) are sometimes asymptomatic, especially in the early phase, and can threaten both the graft and patient's survival. Therefore, the purpose of this study is to analyze the risk factors for portal vein thrombosis (PVT) and portal vein stenosis (PVS) after pediatric LT. METHODS All pediatric patients (n = 115) who underwent primary LT at Regensburg University Hospital between January 2010 and April 2017 were included in this study. The pre-, intra-, and postoperative parameters of all patients were retrospectively reviewed and risk factors for both PVT and PVS were analyzed. RESULTS Of the 115 patients, living donor LT was performed on 57 (49.5%) patients, and biliary atresia was the primary diagnosis in 65 patients (56%). After pediatric LT, 9% of patients developed PVT, and 16.5% developed PVS. Patient weight ≤7 kg [odds ratio (OR) 9.35, 95% confidence interval (CI) 1.03-84.9, p = .04] and GRWR >3% (OR 15.4, 95% CI 1.98-129.5, p = .01) were the independent risk factors for the development of PVT and PVS, respectively upon multivariate analysis. The overall patient survival rates at 1, 3, and 5 years were 91%, 90%, and 89%, respectively, and there was no difference in patient survival among those with and without PVCs. CONCLUSIONS Pediatric patients with body weight <7 kg and/or receiving a graft with GRWR >3% may develop PVCs and so require certain surgical modifications, close follow-up, and prophylactic anticoagulant therapy following transplant.
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Affiliation(s)
- Amr Badawy
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany.,General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Stefan M Brunner
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Birgit Knoppke
- University Children's Hospital of Regensburg (KUNO), Regensburg, Germany
| | - Melanie Völkl
- University Children's Hospital of Regensburg (KUNO), Regensburg, Germany
| | - Henrik Junger
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Martin Loss
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Sinner
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Veronika Huf
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany.,Institute of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Grothues
- University Children's Hospital of Regensburg (KUNO), Regensburg, Germany
| | - Michael Melter
- University Children's Hospital of Regensburg (KUNO), Regensburg, Germany
| | - Hans J Schlitt
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
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8
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Stevens JP, Xiang Y, Leong T, Naik K, Gupta NA. Portal vein complications and outcomes following pediatric liver transplantation: Data from the Society of Pediatric Liver Transplantation. Liver Transpl 2022; 28:1196-1206. [PMID: 35092344 DOI: 10.1002/lt.26412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/06/2022] [Accepted: 01/11/2022] [Indexed: 12/29/2022]
Abstract
Children who undergo liver transplantation are at risk for portal vein complications (PVCs) including thrombosis (PVT) and stenosis (PVS). Using multicenter data from the Society of Pediatric Liver Transplantation, we analyzed the prevalence, timing, and risk factors for PVC following a first liver transplantation, and assessed the potential impact of PVC on patient outcomes. Our cohort included 4278 patients, of whom 327 (7.6%) developed PVC. Multivariate analysis discovered several factors independently associated with PVC: younger recipient age, lower weight at time of transplantation, diagnosis of biliary atresia (BA), receiving a technical variant graft (TVG), warm ischemia time over 3 h, PVT in the recipient's pretransplantation native liver, and concurrent hepatic artery thrombosis (all p < 0.05). Subgroup analysis of those with BA found higher prevalence in patients transplanted at less than 2 years of age and those with TVGs. There was no difference in PVC prevalence among patients with BA with vs. without prior Kasai portoenterostomy. Most PVT (77.7%) presented within 90 days after transplantation. Patients with PVC had a higher risk of graft failure (23.9% vs. 8.3%; adjusted hazard ratio [HR], 3.08; p < 0.001) and a higher risk of death (16.4% vs. 8.9%; adjusted HR, 1.96; p = 0.01). Recurrence after retransplantation was similar to the overall prevalence in the cohort (8.2%). Our results recognize the common occurrence of PVC following pediatric liver transplantation, describe independently associated risk factors, and determine that patients with PVC have worse outcomes. Further studies are needed to improve PVC prevention, detection, and management strategies.
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Affiliation(s)
- James P Stevens
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Transplant Services, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Yijin Xiang
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Traci Leong
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kushal Naik
- Transplant Services, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Nitika Arora Gupta
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Transplant Services, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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9
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Gad EH, Sallam AN, Soliman H, Ibrahim T, Salem TAH, Ali MAH, Al-Sayed Abd-same M, Ayoub I. Pediatric living donor liver transplantation (LDLT): Short- and long-term outcomes during sixteen years period at a single centre- A retrospective cohort study. Ann Med Surg (Lond) 2022; 79:103938. [PMID: 35860167 PMCID: PMC9289343 DOI: 10.1016/j.amsu.2022.103938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric living donor liver transplantation (LDLT) is an effective tool for managing pediatric patients with end-stage liver disease (ESLD) with good long-term graft and patient survival, especially after improvement in peri-operative care, surgical tools and techniques; however, the morbidity and mortality after such a procedure are still a challenging matter. The study aimed to analyze short-and long-term outcomes after pediatric LDLT in a single centre. METHODS We retrospectively analyzed 67 pediatric patients who underwent LDLT in the period from April 2003 to July 2018. The overall male/female ratio was 40/27. RESULTS Forty-one (61.2%) of patients had ≥1 early and/or late morbidities; the early (less than 3months) and late (≥3months) ones affected 36(53.7%) and 12(17.9%) of them respectively. The 16-year graft and patient survivals were 35(52.2%) while early and late mortalities were 23(34.3%) and 9(13.4%) respectively. Sepsis and chronic rejection were the most frequent causes of early and late mortalities respectively. Moreover, more packed RBCs transfusion units, bacterial infections, and pulmonary complications were independent predictors of poor patient survival. CONCLUSIONS More packed RBCs transfusion units intra-operatively, and post-liver transplant (LT) bacterial infection, sepsis, chronic rejection, as well as pulmonary complications had a negative insult on our patients' outcomes, so proper management of them is mandatory for improving outcomes after pediatric LDLT.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | - Ahmed Nabil Sallam
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | - Hosam Soliman
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | - Tarek Ibrahim
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | | | | | | | - Islam Ayoub
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
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10
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Bellini MI, Lauro A, D'Andrea V, Marino IR. Pediatric Liver Transplantation: Long-Term Follow-Up Issues. EXP CLIN TRANSPLANT 2022; 20:27-35. [PMID: 35570596 DOI: 10.6002/ect.pediatricsymp2022.l16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Pediatric liver transplant is an established life-saving procedure for children with end-stage liver diseases, achieving excellent graft and patient survival but with effects on quality of life and psychological welfare in the long-term. With the natural increase in the number of pediatric transplant patients becoming adults, it is essential to successfully plan and manage issues affecting late outcomes in the vulnerable pediatric transplant population. This study offers an overview of the long-term surgical complications, the consequences of immunosuppression (such as posttransplant diabetes, hypertension, cardiovascular disease, and renal dysfunction), and the infection and malignancy risks. Finally, because quality of life is now an inclusive measurement of patient satisfaction, guidance on how to facilitate the transition to adulthood, empowering transplant recipients, is also provided.
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11
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Gad EH, Ayoup E, Aziz AM, Ibrahim T, Elhelbawy M, Abd-elsamee MAS, Sallam AN. Biliary complications after adult to adult right-lobe living donor liver transplantation (A-ARLLDLT): Analysis of 245 cases during 16 years period at a single high centre- A retrospective cohort study. Ann Med Surg (Lond) 2022. [DOI: https:/doi.org/10.1016/j.amsu.2022.103577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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12
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Gad EH, Ayoup E, Aziz AM, Ibrahim T, Elhelbawy M, Abd-elsamee MAS, Sallam AN. Biliary complications after adult to adult right-lobe living donor liver transplantation (A-ARLLDLT): Analysis of 245 cases during 16 years period at a single high centre- A retrospective cohort study. Ann Med Surg (Lond) 2022. [DOI: https://doi.org/10.1016/j.amsu.2022.103577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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13
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Gad EH, Ayoup E, Aziz AM, Ibrahim T, Elhelbawy M, Abd-elsamee MAS, Sallam AN. Biliary complications after adult to adult right-lobe living donor liver transplantation (A-ARLLDLT): Analysis of 245 cases during 16 years period at a single high centre- A retrospective cohort study. Ann Med Surg (Lond) 2022; 77:103577. [PMID: 35638038 PMCID: PMC9142388 DOI: 10.1016/j.amsu.2022.103577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Biliary complications (BCs) after adult to adult living donor liver transplantation (A-ALDLT) result in poor graft and patient survival. This study aimed to analyze these complications. METHODS We retrospectively analyzed BCs in 245 recipients who underwent A-ALDLT using the right-lobe graft during 16 years period in our centre. The overall male/female ratio was 215/30. RESULTS One hundred fifty-five BCs affected 102 of our recipients (95 early (≤3months) and 60 late (≥3months)). They were classified as 67/245(27.3%) early bile leak, 10/245(4.1%) early biliary stricture, 44/245(17.9%) late biliary stricture, 4/245(1.6%) early cholangitis, 10/245(4.1%) late cholangitis, 14/245(5.7%) early biloma, and 6/245(2.4%) late cholangitic abscesses. Multiple biliary anastomoses were independently correlated with Post liver transplantation (LT) overall BCs; moreover, post LT hepatic artery thrombosis or stenosis (HAT/S) was an independent predictor of overall BCs, strictures and leaks. The mortality affected 96(39.2%) cases mostly due to sepsis, bleeding and multi-organ failure (MOF). On the other hand, the biliary related mortality was 10.6% of cases. Multiple cholangitic hepatic abscesses were significant predictors of poor graft and patient outcomes. Conclusions: Multiple biliary anastomoses and post LT HAT/S lead to a poor biliary outcome, furthermore, cholangitis, cholangitic abscesses and sepsis lead to poor graft and patient outcomes, so proper management of those variables is mandatory to improve outcomes after A-ARLLDLT.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | - Eslam Ayoup
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | - Amr M. Aziz
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | - Tarek Ibrahim
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | - Mostafa Elhelbawy
- Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | | | - Ahmed Nabil Sallam
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
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14
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Ghidini F, Benetti E, Zucchetta P, Amigoni A, Gamba P, Castagnetti M. Transcutaneous near-infrared spectroscopy (NIRS) for monitoring kidney and liver allograft perfusion. Int J Clin Pract 2021; 75:e14034. [PMID: 33470001 DOI: 10.1111/ijcp.14034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 01/17/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The use of transcutaneous near-infrared spectroscopy (NIRS) for monitoring the perfusion of kidney and liver allografts has been proposed in the last years. This device might detect an early decrease in allograft oxygenation allowing prompt detection of vascular complications. METHODS A systematic review of the literature about the use of transcutaneous NIRS in monitoring allograft perfusion was performed according to the PRISMA guidelines. RESULTS The authors screened 1313 papers. The search yielded five pertinent articles. Three of them reported the experience of NIRS in kidney transplantation and the other two dealt with its use in liver transplantation, for a total of 55 paediatric patients and 121 adults. In the studies concerning kidney transplantation, NIRS measurements were significantly related to serum creatinine, estimated glomerular filtration rate (eGFR), urinary neutrophil gelatinase-associated lipocalin (u-NGAL), serum lactate, resistive index assessed by Doppler-ultrasonography and systolic blood pressure. The two studies dealing with liver transplantation found a significant decrease in liver regional oxygenation, assessed by NIRS, before the occurrence of vascular complications. CONCLUSIONS Preliminary studies have related NIRS monitoring to kidney and liver allograft perfusion, both in adults and children. Further investigation is needed to establish the normal range of NIRS values and the factors influencing NIRS monitoring.
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Affiliation(s)
- Filippo Ghidini
- Pediatric Urology, Department of Women's and Children's Health, University of Padua, Padua, Italy
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Elisa Benetti
- Pediatric Nephrology, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Pietro Zucchetta
- Nuclear Medicine, Department of Medicine, University of Padua, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Marco Castagnetti
- Pediatric Urology, Department of Women's and Children's Health, University of Padua, Padua, Italy
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padua, Padua, Italy
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15
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Calinescu AM, Wildhaber BE. Early Vascular Complications. PEDIATRIC LIVER TRANSPLANTATION 2021:181-191. [DOI: 10.1016/b978-0-323-63671-1.00020-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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16
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Shi Y, Su Y, Li C, Shi H, Liang Y. Revascularization of iatrogenic intraoperative injury to a major artery during hepatobiliary-pancreatic surgery: a single-center experience in China. Minerva Surg 2020; 76:388-394. [PMID: 33161698 DOI: 10.23736/s2724-5691.18.07546-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although uncommon during hepatobiliary-pancreatic (HBP) surgery, iatrogenic intraoperative injury to a major artery requires prompt and appropriate repair. Here, we outline our surgical experience with the repair of this injury and compare our experience to findings garnered from a selective review of the literature. METHODS We retrospectively analyzed the clinical diagnoses, surgical methods, sites of arterial injury, operative repair, intra-operative blood loss, blood transfusion requirements, postoperative management and outcome of 17 consecutive patients who sustained iatrogenic intra-operative injuries to major arteries during HBP surgery between January 2008 and December 2013. RESULTS Depending on the location and extent of injury, suture repair, primary end-to-end anastomosis, artery transposition, interposition grafting, or arterio-portal shunting were used. Postoperative morbidity occurred in three cases and there was only one case of in-hospital mortality (5.9%). No arterial thrombosis or other repair-related complications were found after the operation with a follow-up duration of 6 months. CONCLUSIONS The use of an optimal repair method for injured arteries based on their location and extent resulted in a satisfactory outcome.
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Affiliation(s)
- Yong Shi
- Chinese PLA Medical School, Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yinan Su
- Chinese PLA Medical School, Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, China
| | - Chonghui Li
- Chinese PLA Medical School, Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, China
| | - Haida Shi
- Chinese PLA Medical School, Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yurong Liang
- Chinese PLA Medical School, Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, China -
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Gu LH, Fang H, Liu XS, Xia Q, Li FH. Additional value of superb microvascular imaging for assessing hepatic arterial blood flow after pediatric liver transplantation. Pediatr Transplant 2020; 24:e13785. [PMID: 32871039 DOI: 10.1111/petr.13785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/04/2020] [Accepted: 06/10/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of this study was to explore the value of SMI compared with conventional ultrasonography for assessing hepatic arterial blood flow after pediatric liver transplantation. METHODS From March 2018 to November 2018, a total of 105 pediatric recipients with biliary atresia underwent liver transplantation in our hospital. Ultrasound examinations were performed at the bedside in the intensive care unit to check the patency of the blood flow in the hepatic allograft. CDI, PDI, cSMI, and mSMI were performed to assess the display, orientation, and distribution of the graft hepatic artery. Ultrasound examinations were performed by one radiologist, and the images were judged by two observers. RESULTS The median age, weight, and height of the recipients were 6.97 (5.92, 9.58) months, 6.50 (6.00, 7.80) kg, and 64.00 (62.00, 68.00) cm, respectively. The measure of kappa agreement was 0.902, 0.889, 0.882, and 0.882 for CDI, PDI, cSMI, and mSMI, respectively. HAT occurred in 7 pediatric recipients and was confirmed by CTA (computed tomography angiography) and surgery. The diagnostic performance of sensitivity, specificity, PPV (positive predictive value), NPV (negative predictive value), and accuracy were 100%, 92.86%, 50%, 100%, and 93.33% for CDI and 100%, 98.98%, 87.50%, 100%, and 99.05% for SMI. CONCLUSIONS As an additional method to CDI, SMI can clearly show the distribution of hepatic arterial blood flow and provide more details, thereby markedly improving the diagnostic performance of postoperative HAT.
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Affiliation(s)
- Li-Hong Gu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Hua Fang
- Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xue-Song Liu
- Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Feng-Hua Li
- Department of Ultrasound, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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18
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Yin C, Zhu ZJ, Wei L, Sun LY, Zhang HM, Wu HR. Risk factors for portal vein stenosis in pediatric liver transplantation. Clin Transplant 2020; 34:e13992. [PMID: 32453915 DOI: 10.1111/ctr.13992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 05/06/2020] [Accepted: 05/16/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To analyze the incidence and risk factors of portal vein stenosis (PVS) in pediatric liver transplantation (LT). METHODS This retrospective analysis of 396 cases of pediatric LT (patients aged ≤ 14 years old) was conducted at the Liver Transplantation Center of Beijing Friendship Hospital (China) from June 2013 to December 2017. We collected relevant data and calculated the incidence. We analyzed a total of 23 risk factors for PVS children during the perioperative period. RESULTS The incidence of PVS in pediatric LT was 6.6%. The following were identified as risk factors for PVS in pediatric LT: Preoperative portal hypertension was complicated, weight (≤7 kg), recipients of portal vein diameter ≤4 mm, GRWR (≥3.5%), the use of cold preservation vein grafts, anastomosis in the region of superior mesenteric vein and splenic vein and reverse blood flow in the portal vein shown in preoperative ultrasound examination. Recipients of portal vein diameter ≤4 mm and the use cold preservation grafts were independent risks factors for PVS in pediatric LT. CONCLUSION For recipients with the risk factors identified in this study, we strongly recommend a strict follow-up and the provision of suitable interventions when indicated.
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Affiliation(s)
- Chao Yin
- Liver Transplant Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhi-Jun Zhu
- Liver Transplant Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lin Wei
- Liver Transplant Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Li-Ying Sun
- Liver Transplant Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hai-Ming Zhang
- Liver Transplant Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hai-Rui Wu
- Liver Transplant Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Gad EH, Kamel Y, Alsebaey A, Mohammed A, Abdelsamee MA. Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study. Ann Med Surg (Lond) 2020. [DOI: https:/doi.org/10.1016/j.amsu.2020.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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20
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Gad EH, Kamel Y, Alsebaey A, Mohammed A, Abdelsamee MA. Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study. Ann Med Surg (Lond) 2020. [DOI: https://doi.org/10.1016/j.amsu.2020.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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21
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Gad EH, Kamel Y, Alsebaey A, Mohammed A, Abdelsamee MA. Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study. Ann Med Surg (Lond) 2020; 51:1-10. [PMID: 31993197 PMCID: PMC6976867 DOI: 10.1016/j.amsu.2020.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 01/04/2020] [Indexed: 02/08/2023] Open
Abstract
UNLABELLED With improved laparoscopic techniques, experience, and availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy (LC) became a feasible option in cirrhotic patients, the aim of this study was to analyze the outcome of LC in cirrhotic patients. METHODS We retrospectively analyzed 213 cirrhotic patients underwent LC, in the period from 2011 to 2019; the overall male/female ratio was 114/99. RESULTS The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities. CONCLUSION LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Yasmin Kamel
- Hepatology, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ayman Alsebaey
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Anwar Mohammed
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
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22
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Gad EH, Kamel Y, Alsebaey A, Mohammed A, Abdelsamee MA. Laparoscopic cholecystectomy in patients with liver cirrhosis: 8 years experience in a tertiary center. A retrospective cohort study. ANNALS OF MEDICINE AND SURGERY (2012) 2020. [PMID: 31993197 DOI: 10.1016/j.amsu.2020.01.003.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
With improved laparoscopic techniques, experience, and availability of newer tools and instruments like ultrasonic shears; laparoscopic cholecystectomy (LC) became a feasible option in cirrhotic patients, the aim of this study was to analyze the outcome of LC in cirrhotic patients. METHODS We retrospectively analyzed 213 cirrhotic patients underwent LC, in the period from 2011 to 2019; the overall male/female ratio was 114/99. RESULTS The most frequent Child-Turcotte-Pugh (CTP) score was A, The most frequent cause of cirrhosis was hepatitis C virus (HCV), while biliary colic was the most frequent presentation. The harmonic device was used in 39.9% of patients, with a significant correlation between it and lower operative bleeding, lower blood and plasma transfusion rates, higher operative adhesions rates, lower conversion to open surgery and 30-day complication rates, shorter operative time and post-operative hospital stays where operative adhesions and times were independently correlated. The 30-day morbidity and mortality were 22.1% and 2.3% respectively while overall survival was 91.5%, higher CTP, and model for end-stage liver disease (MELD) scores, higher mean international normalization ratio (INR) value, lower mean platelet count, higher operative bleeding, higher blood, and plasma transfusion rates, longer mean operative time and postoperative hospital stays were significantly correlated with all conversion to open surgery, 30-day morbidities and mortalities. CONCLUSION LC can be safely performed in cirrhotic patients. However, higher CTP and MELD scores, operative bleeding, more blood and plasma transfusion units, longer operative time, lower platelet count, and higher INR values are predictors of poor outcome that can be improved by proper patient selection and meticulous peri-operative care and by using Harmonic scalpel shears.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Yasmin Kamel
- Hepatology, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ayman Alsebaey
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Anwar Mohammed
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
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Kim JS, Kim KW, Choi SH, Jeong SY, Kwon JH, Song GW, Lee SG. Hepatic Artery Occlusion after Liver Transplantation in Patients with Doppler Ultrasound Abnormality: Increasing Sensitivity of Contrast-Enhanced Ultrasound Diagnosis. Korean J Radiol 2019; 20:459-468. [PMID: 30799577 PMCID: PMC6389810 DOI: 10.3348/kjr.2018.0464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/05/2018] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To investigate whether diagnostic performance of contrast-enhanced ultrasound (CEUS) could be improved with modified criteria to diagnose significant hepatic artery occlusion (HAO) and to determine the role of CEUS in patients with a tardus-parvus hepatic artery (HA) pattern on Doppler US. MATERIALS AND METHODS Among 2679 adult liver transplantations performed over 7 years, HAO was suspected in 288 recipients, based on Doppler ultrasound. Among them, 130 patients underwent CEUS. After excluding two technical failures, 128 CEUS images were retrospectively reviewed to search for abnormal findings, such as no HA enhancement, abnormal HA enhancement (delayed, faint, and discontinuous enhancement), and perfusion defect in the liver parenchyma. The performance CEUS abnormalities were assessed in the patients overall and in subgroups based on Doppler ultrasound abnormality (group A, no flow; group B, tardus-parvus pattern) and were compared based on the area under the receiver operating characteristic curve (AUC). RESULTS HAO were diagnosed in 41 patients by surgery, angiography, or follow-up abnormality. By using the conventional criterion (no HA enhancement) to diagnose HAO in patients overall, the sensitivity, specificity, and AUC were 58.5%, 100%, and 0.793, respectively. Modified criteria for HAO (no HA enhancement, abnormal enhancement, or parenchymal perfusion defect) showed statistically significantly increased sensitivity (97.6%, 40/41) and AUC (0.959) (p < 0.001), although the specificity (95.4%, 83/87) was slightly decreased. The sensitivity and specificity of the modified criteria in Groups A and B were 97.1% (33/34) and 95.7% (22/23), and 100% (7/7) and 95.3% (61/64), respectively. CONCLUSION Modified criteria could improve diagnostic performance of CEUS for HAO, particularly by increasing sensitivity. CEUS could be useful for diagnosing HAO even in patients with a tardus-parvus HA pattern on Doppler US, using modified criteria.
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Affiliation(s)
- Jin Sil Kim
- Department of Radiology and Medical Research Institute, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Kyoung Won Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Sang Hyun Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So Yeong Jeong
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hyun Kwon
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi Won Song
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Gyu Lee
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kim JS, Kim KW, Lee J, Kwon HJ, Kwon JH, Song GW, Lee SG. Diagnostic Performance for Hepatic Artery Occlusion After Liver Transplantation: Computed Tomography Angiography Versus Contrast-Enhanced Ultrasound. Liver Transpl 2019; 25:1651-1660. [PMID: 31206222 DOI: 10.1002/lt.25588] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/09/2019] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to compare the diagnostic performance of computed tomography angiography (CTA) and contrast-enhanced ultrasound (CEUS) when used to diagnose significant hepatic artery occlusion (HAO) in patients that was suspected on Doppler ultrasound (US). Among 3465 adult liver transplantations (LTs) performed between January 2010 and February 2018, 329 recipients were suspected of having HAO by Doppler US. In these patients, 139 recipients who had undergone both CTA and CEUS as second-line studies were included. CTA and CEUS were retrospectively reviewed using the criteria for HAO used in previous studies (CTA, ≥50% stenosis at the anastomosis; CEUS, no HA enhancement or delayed and discontinuous enhancement). The diagnostic values of CTA and CEUS were compared using the McNemar test. CEUS showed statistically significant better accuracy and specificity than CTA in patients with Doppler US abnormality seen after LT (accuracy, 99.3% versus 89.2%, P < 0.001; specificity, 100% versus 83.1%, P < 0.001). CTA had 15 false-positive diagnoses, and CEUS had 1 false-negative diagnosis. In conclusion, CEUS showed higher specificity and positive predictive value than CTA for the diagnosis of HAO in selected patients with a Doppler US abnormality. However, even if there is no HAO diagnosed on CEUS, continuous monitoring and follow-up imaging are required when HAO is strongly suspected in the clinical setting and on CTA.
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Affiliation(s)
- Jin Sil Kim
- Department of Radiology and Medical Research Institute, School of Medicine, Ewha Womans University, Seoul, South Korea
| | - Kyoung Won Kim
- Department of Radiology, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeongjin Lee
- School of Computer Science and Engineering, Soongsil University, Seoul, South Korea
| | - Heon-Ju Kwon
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Hyun Kwon
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gi Won Song
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Gyu Lee
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Gad EH, Zakaria H, Kamel Y, Alsebaey A, Zakareya T, Abbasy M, Mohamed A, Nada A, Abdelsamee MA, Housseni M. Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study. Ann Med Surg (Lond) 2019. [DOI: https:/doi.org/10.1016/j.amsu.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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26
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Gad EH, Zakaria H, Kamel Y, Alsebaey A, Zakareya T, Abbasy M, Mohamed A, Nada A, Abdelsamee MA, Housseni M. Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study. Ann Med Surg (Lond) 2019; 43:52-63. [PMID: 31198552 PMCID: PMC6556483 DOI: 10.1016/j.amsu.2019.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/18/2019] [Accepted: 05/23/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure. METHODS We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018. RESULTS Sixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay. CONCLUSION Large difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Hazem Zakaria
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Yasmin Kamel
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ayman Alsebaey
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Talat Zakareya
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Abbasy
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Anwar Mohamed
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ali Nada
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | | | - Mohamed Housseni
- Intervention Radiology, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
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Gad EH, Zakaria H, Kamel Y, Alsebaey A, Zakareya T, Abbasy M, Mohamed A, Nada A, Abdelsamee MA, Housseni M. Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study. Ann Med Surg (Lond) 2019. [DOI: https://doi.org/10.1016/j.amsu.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Gad EH, Zakaria H, Kamel Y, Alsebaey A, Zakareya T, Abbasy M, Mohamed A, Nada A, Abdelsamee MA, Housseni M. Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study. ANNALS OF MEDICINE AND SURGERY (2012) 2019. [PMID: 31198552 DOI: 10.1016/j.amsu.2019.05.007.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/01/2022]
Abstract
Objectives For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure. Methods We analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018. Results Sixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay. Conclusion Large difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Hazem Zakaria
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Yasmin Kamel
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ayman Alsebaey
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Talat Zakareya
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Abbasy
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Anwar Mohamed
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ali Nada
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | | | - Mohamed Housseni
- Intervention Radiology, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
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Kutluturk K, Sahin TT, Karakas S, Unal B, Gozukara Bag HG, Akbulut S, Aydin C, Yilmaz S. Early Hepatic Artery Thrombosis After Pediatric Living Donor Liver Transplantation. Transplant Proc 2019; 51:1162-1168. [PMID: 31101192 DOI: 10.1016/j.transproceed.2019.01.104] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 01/21/2019] [Indexed: 02/07/2023]
Abstract
AIM Hepatic artery thrombosis is one of the major complications affecting patient and graft survival after liver transplantation. In this study, we analyzed the factors affecting the development of early hepatic artery thrombosis (eHAT) and its outcomes in pediatric liver transplantation. METHODS A total of 175 pediatric patients underwent living donor liver transplantation between January 2013 and November 2018. Factors affecting eHAT and its outcomes were examined. RESULTS Nine patients (5.1%) developed eHAT. In multivariate analysis, intraoperative hepatic artery revision and Roux-en-Y hepaticojejunostomy biliary reconstruction type were statistically significant (all, P < .05). Thrombectomy and reanastomosis was performed in 5 patients. Two of them were successful. In total, 3 retransplantations were performed and all of those patients are still alive. CONCLUSION The factors affecting eHAT are still a matter of debate. Intraoperative hepatic artery anastomosis revision and Roux-en-Y hepaticojejunostomy reconstruction were independent risk factors for development of eHAT. In the present study, the confidence interval of the variables is high, therefore exact determination of the risk factors may not be possible. Early detection and thrombectomy and reanastomosis may be the first treatment of choice to rescue the patient and graft. When it fails, retransplantation must be an alternative. The results of the present study state that at least once a day the vascular anastomosis must be examined by Doppler ultrasonography in the post-transplant first week. It must be repeated when liver enzymes increase. The patients under high risk for eHAT may be followed up closer.
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Affiliation(s)
- K Kutluturk
- Inonu University Institute of Liver Transplantation, Malatya, Turkey.
| | - T T Sahin
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - S Karakas
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - B Unal
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - H G Gozukara Bag
- Inonu University Faculty of Medicine Department of Biostatistics and Bioinformatics, Malatya, Turkey
| | - S Akbulut
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - C Aydin
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
| | - S Yilmaz
- Inonu University Institute of Liver Transplantation, Malatya, Turkey
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Black CK, Termanini KM, Aguirre O, Hawksworth JS, Sosin M. Solid organ transplantation in the 21 st century. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:409. [PMID: 30498736 PMCID: PMC6230860 DOI: 10.21037/atm.2018.09.68] [Citation(s) in RCA: 195] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 09/29/2018] [Indexed: 12/20/2022]
Abstract
Solid organ transplantation (SOT) has emerged from an experimental approach in the 20th century to now being an established and practical definitive treatment option for patients with end-organ dysfunction. The evolution of SOT has seen the field progress rapidly over the past few decades with incorporation of a variety of solid organs-liver, kidney, pancreas, heart, and lung-into the donor pool. New advancements in surgical technique have allowed for more efficient and refined multi-organ procurements with minimal complications and decreased ischemic injury events. Additionally, immunosuppression therapy has also seen advancements with the expansion of immunosuppressive protocols to dampen the host immune response and improve short and long-term graft survival. However, the field of SOT faces new barriers, most importantly the expanding demand for SOT that is outpacing the current supply. Allocation protocols have been developed in an attempt to address these concerns. Other avenues for SOT are also being explored to increase the donor pool, including split-liver donor transplants, islet cell implantation for pancreas transplants, and xenotransplantation. The future of SOT is bright with exciting new research being explored to overcome current obstacles.
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Affiliation(s)
- Cara K. Black
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Oswaldo Aguirre
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC, USA
| | - Jason S. Hawksworth
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC, USA
| | - Michael Sosin
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
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De Pietri L, Montalti R, Nicolini D, Troisi RI, Moccheggiani F, Vivarelli M. Perioperative thromboprophylaxis in liver transplant patients. World J Gastroenterol 2018; 24:2931-2948. [PMID: 30038462 PMCID: PMC6054944 DOI: 10.3748/wjg.v24.i27.2931] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/17/2018] [Accepted: 06/22/2018] [Indexed: 02/06/2023] Open
Abstract
Improvements in surgical and anesthetic procedures have increased patient survival after liver transplantation (LT). However, the perioperative period of LT can still be affected by several complications. Among these, thromboembolic complications (intracardiac thrombosis, pulmonary embolism, hepatic artery and portal vein thrombosis) are relatively common causes of increased morbidity and mortality. The benefit of thromboprophylaxis in general surgical patients has already been established, but it is not the standard of care in LT recipients. LT is associated with a high bleeding risk, as it is performed in a setting of already unstable hemostasis. For this reason, the role of routine perioperative prophylactic anticoagulation is usually restricted. However, recent data have shown that the bleeding tendency of cirrhotic patients is not an expression of an acquired bleeding disorder but rather of coexisting factors (portal hypertension, hypervolemia and infections). Furthermore, in cirrhotic patients, the new paradigm of ''rebalanced hemostasis'' can easily tip towards hypercoagulability because of the recently described enhanced thrombin generation, procoagulant changes in fibrin structure and platelet hyperreactivity. This new coagulation balance, along with improvements in surgical techniques and critical support, has led to a dramatic reduction in transfusion requirements, and the intraoperative thromboembolic-favoring factors (venous stasis, vessels clamping, surgical injury) have increased the awareness of thrombotic complications and led clinicians to reconsider the limited use of anticoagulants or antiplatelets in the postoperative period of LT.
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Affiliation(s)
- Lesley De Pietri
- Division of Anaesthesiology and Intensive Care Unit, Department of General Surgery, AUSL Reggio Emilia-IRCCS, Reggio Emilia 42123, Italy
| | - Roberto Montalti
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Daniele Nicolini
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Roberto Ivan Troisi
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital Medical School, Ghent 185 3K3 9000, Belgium
- Department of Clinical Medicine, Federico II University Naples, Naples 80138, Italy
| | - Federico Moccheggiani
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
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Zheng BW, Tan YY, Fu BS, Tong G, Wu T, Wu LL, Meng XC, Zheng RQ, Yi SH, Ren J. Tardus parvus waveforms in Doppler ultrasonography for hepatic artery stenosis after liver transplantation: can a new cut-off value guide the next step? Abdom Radiol (NY) 2018; 43:1634-1641. [PMID: 29063132 PMCID: PMC6061483 DOI: 10.1007/s00261-017-1358-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE Considering the high false-positive diagnosis of the tardus parvus waveform (TPW) in Doppler ultrasonography (DUS) for hepatic artery stenosis (HAS) after liver transplantation (LT), this study aimed to determine clinical features and new cut-off values to help guide treatment. MATERIALS AND METHODS This retrospective study was approved by an Institutional Review Board. A total of 171 LT recipients were included and underwent DUS and either computed tomography angiography or digital subtraction angiography with an interval < 4 weeks at least 1 month post-LT. The DUS of 69 patients exhibited TPW [defined as resistive index (RI) < 0.5 and systolic acceleration time (SAT) > 0.08 s]. A multilevel likelihood ratio (LR) analysis was used to explore new cut-off values for DUS. In addition, abnormal liver function was considered additional evidence (defined as any liver enzyme > 3-fold of the upper limit of normal level or 2-fold increased). The results were stratified into three categories, category 1 (subjects with traditional TPW), category 2 (subjects with traditional TPW and abnormal liver function), and category 3 (subjects with traditional TPW and abnormal liver function, or with new cut-off values), and the diagnostic performance of each category was analyzed. RESULTS The LR analysis revealed new cut-off values of RI < 0.4 (LR = 10.58) or SAT > 0.12 s (LR = 16.46). The false-positive rates for categories 2 and 3 were significantly lower (7.6% vs. 18.1%, P = 0.038; 1.9% vs. 18.1%, P < 0.001, respectively) than those for category 1, while the sensitivity for category 2 was significantly lower (41.8% vs. 74.6%, P < 0.001; 41.8% vs. 61.2%, P = 0.038, respectively) than that for categories 1 and 3. CONCLUSION Using either (1) RI < 0.4 or SAT > 0.12 s, or (2) traditional TPW (RI < 0.5 and SAT > 0.08 s) in the presence of abnormal liver functions as the DUS criteria for HAS will significantly decrease the false-positive rate compared to traditional TPW without a significant increase in the false-negative rate.
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Affiliation(s)
- Bo-Wen Zheng
- Guangdong Province Key Laboratory of Hepatology Research, Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, People's Republic of China
| | - Ying-Yi Tan
- Guangdong Province Key Laboratory of Hepatology Research, Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, People's Republic of China
| | - Bin-Sheng Fu
- Guangdong Province Key Laboratory of Hepatology Research, Department of Liver Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, People's Republic of China
| | - Ge Tong
- Guangdong Province Key Laboratory of Hepatology Research, Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, People's Republic of China
| | - Tao Wu
- Guangdong Province Key Laboratory of Hepatology Research, Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, People's Republic of China
| | - Li-Li Wu
- Guangdong Province Key Laboratory of Hepatology Research, Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, People's Republic of China
| | - Xiao-Chun Meng
- Department of Radiology, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Erheng Road, Guangzhou, Guangdong, People's Republic of China
| | - Rong-Qin Zheng
- Guangdong Province Key Laboratory of Hepatology Research, Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, People's Republic of China
| | - Shu-Hong Yi
- Guangdong Province Key Laboratory of Hepatology Research, Department of Liver Transplantation, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, People's Republic of China.
| | - Jie Ren
- Guangdong Province Key Laboratory of Hepatology Research, Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, People's Republic of China.
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Endovascular Treatment for Very Early Hepatic Artery Stenosis Following Living-Donor Liver Transplantation: Report of Two Cases. Transplant Proc 2018; 50:1457-1460. [DOI: 10.1016/j.transproceed.2018.02.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/17/2018] [Accepted: 02/06/2018] [Indexed: 12/11/2022]
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Voulgarelis S, Vitola B, Lerret SM, Hong JC, Scott JP. Perioperative anticoagulation practices for pediatric liver transplantation. Pediatr Transplant 2018; 22:e13193. [PMID: 29663585 DOI: 10.1111/petr.13193] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 12/13/2022]
Abstract
Despite continued advancements in perioperative care for pediatric liver transplant (LT), graft-threatening vascular occlusion events including hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT) remain a source of significant morbidity and mortality. Perioperative anticoagulation is commonly used for the prevention of HAT and PVT, but evidence-based guidelines are lacking. The goals of this survey were to determine the frequency of use of an anticoagulation protocol and to describe variation in anticoagulation practices among pediatric LT centers. The study consisted of an online survey distributed to members of SPLIT. The survey focused on institutional anticoagulation practices employed to reduce the incidence of graft and life-threatening vascular occlusion events. Responses were received from 31 of 39 SPLIT centers. All respondents report using anticoagulation after pediatric LT, and approximately 90% have institutional anticoagulation protocols. Subgroup analysis of high volume pediatric LT centers revealed similar variability in anticoagulation patterns. All participating SPLIT centers reported the use of post-transplant anticoagulation and nearly all use a protocol. However, there is marked variability in the type and dose of anticoagulation as well as the timing of initiation and duration of therapy across centers.
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Affiliation(s)
- Stylianos Voulgarelis
- Divisions of Pediatric and Adult Cardiac Anesthesiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Bernadette Vitola
- Division of Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Stacee M Lerret
- Division of Gastroenterology and Transplant Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Johnny C Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - John P Scott
- Divisions of Pediatric Anesthesiology and Pediatric Critical Care, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Pediatric Liver Transplant Anesthesia, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Pediatric Intensive Care Unit, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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35
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Clinical Efficacy of Percutaneous Transhepatic Portal Vein Angioplasty for Late-onset Portal Vein Stenosis in Pediatric Liver Transplant Patients. Transplantation 2018; 102:e282-e287. [PMID: 29470353 DOI: 10.1097/tp.0000000000002138] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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36
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Shiba J, Satoh M, Taira K, Niwa Y, Inoue S, Mizuta K, Takeuchi M. Near-infrared spectroscopy might be a useful tool for predicting the risk of vascular complications after pediatric liver transplants: Two case reports. Pediatr Transplant 2018; 22. [PMID: 29160012 DOI: 10.1111/petr.13089] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 12/28/2022]
Abstract
In patients that have undergone liver transplants, a postoperative reduction in the blood flow of the liver graft represents a critical complication. We recently encountered an interesting phenomenon; that is, we found that the rSO2 level of the liver graft, as measured by NIRS, drops in patients that subsequently require an emergency liver biopsy. An 8-month-old female and an 8-month-old male underwent living donor liver transplants for biliary atresia. In both cases, a reduction in rSO2 was detected before an emergency liver biopsy was required. As a result of biopsy examinations, both patients were diagnosed with acute graft rejection. NIRS might be useful for graft management during the postoperative period in pediatric patients that undergo liver transplantation. After a liver transplant, a reduction in the rSO2 of the graft might be indicative of the onset of vascular complications.
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Affiliation(s)
- Juntaro Shiba
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Shimotuke, Japan
| | - Masaaki Satoh
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Shimotuke, Japan
| | - Koki Taira
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Shimotuke, Japan
| | - Yasunori Niwa
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Shimotuke, Japan
| | - Soichiro Inoue
- Department of Anesthesiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Koichi Mizuta
- Department of Transplant Surgery, Jichi Medical University, Shimotuke, Japan
| | - Mamoru Takeuchi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Shimotuke, Japan
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Thrombosis after liver transplantation for hepatocellular carcinoma. PLoS One 2017; 12:e0186699. [PMID: 29073275 PMCID: PMC5658078 DOI: 10.1371/journal.pone.0186699] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 10/05/2017] [Indexed: 12/21/2022] Open
Abstract
The influence of thrombosis on the prognosis of patients with hepatocellular carcinoma (HCC) after liver transplantation (LT) and the role of the commonest inherited thrombophilia abnormalities factor V Leiden and prothrombin G20210A in the development of thrombosis are unknown. We investigated a cohort of patients who underwent LT for HCC with the aim to estimate the incidence rate (IR) of thrombosis, its influence on mortality and re-transplantation rates and, in the frame of a nested case-control study, the role of thrombophilia in donors and recipients for the development of thrombosis. Four-hundred and thirty patients underwent LT and were followed for a median of 7.2 years. Twenty-six recipients (6%) developed thrombosis (IR 1.06 [95%CI: 0.71–1.53] per 100 pts-yr). Mortality rate after LT was 3.95 (95%CI: 3.22–4.79) per 100 pts-yr and was not influenced by thrombosis. Re-transplantation was planned for 33 patients and was more common in patients with thrombosis than in those without (HR 2.50 [95%CI: 0.87–7.17]). The risk of thrombosis was 4 times higher in recipients with thrombophilia than in those without (OR 4.23 [95%CI: 0.99–18.04]) and 6 times higher when the analysis was restricted to venous thrombosis (OR 6.26 [95%CI: 1.19–32.85]). The presence of inherited thrombophilia in the donors did not increase the risk of thrombosis of the recipient. In conclusion, thrombosis is a complication of 6% of patients transplanted for HCC and increases the risk of re-transplantation but not of mortality. The risk of thrombosis, particularly venous, is increased in the presence of thrombophilia abnormalities in the recipients.
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Li PC, Thorat A, Jeng LB, Yang HR, Li ML, Yeh CC, Chen TH, Hsu SC, Poon KS. Hepatic artery reconstruction in living donor liver transplantation using surgical loupes: Achieving low rate of hepatic arterial thrombosis in 741 consecutive recipients-tips and tricks to overcome the poor hepatic arterial flow. Liver Transpl 2017; 23:887-898. [PMID: 28422392 DOI: 10.1002/lt.24775] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 04/09/2017] [Accepted: 04/13/2017] [Indexed: 12/17/2022]
Abstract
The reconstruction of the hepatic artery (HA) is the most complex step in living donor liver transplantation (LDLT) because of the smaller diameter of the artery and the increased risk of HA-related complications. Because of the smaller diameter of the HA, many centers use a microsurgical technique with interrupted sutures for arterial anastomosis. The aim of our study was to retrospectively investigate the outcomes after HA reconstruction performed under magnifying loupes using the "parachute technique." From August 1, 2002 to August 31, 2016, LDLT was performed in 766 recipients. HA reconstruction for the initial 25 LDLT surgeries was performed using a microsurgery technique (era 1). From May 2007 until the end date, HA reconstruction was performed in 741 recipients by a "parachute technique" under surgical loupes (era 2). HA reconstruction was performed using surgical loupes in 737 adults (male:female, 526:211) and 4 pediatric patients (male:female, 3:1). The average diameter of the donor graft HA was 2.8 mm (range, 1-6.5 mm). The most notable factor in this era was the quick HA anastomosis procedure with a mean time of 10 ± 5 minutes (range, 5-30 minutes). In era 2, 9 (1.21%) patients developed hepatic artery thrombosis (HAT), whereas 2 patients developed nonthrombotic HA-related complications. Extra-anatomic HA reconstruction was performed in 14 patients due to either primary HA anastomosis failure or a poor caliber recipient HA. The use of magnifying surgical loupes to perform HA reconstruction is safe, feasible, and yields a low incidence of HA-related complications. The "parachute technique" for HA reconstruction can achieve a speedy reconstruction without increasing the risk of HAT. Liver Transplantation 23 887-898 2017 AASLD.
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Affiliation(s)
- Ping-Chun Li
- Organ Transplantation Center.,Departments of Cardiovascular Surgery
| | | | | | | | - Ming-Li Li
- Organ Transplantation Center.,Departments of Cardiovascular Surgery
| | | | | | | | - Kin-Shing Poon
- Organ Transplantation Center.,Anaesthesiology, China Medical University Hospital, Taichung, Taiwan
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