• Cirrhosis
• Left renal vein
• Liver transplantation
• Splenorenal shunt

• liver cirrhosis
• liver transplantation
• portal vein thrombosis
• survival

• PVT
• Pull-out technique
• double-approach procedure
• liver transplantation
• portal hypertension

A large spontaneous splenorenal shunt (SRS) will greatly impact portal inflow to the graft during liver transplantation (LT). Direct ligation of a large SRS is an uncommon surgical procedure and the hemodynamic consequences of this procedure are unknown.

In this retrospective study, we described our technique for direct ligation of a large SRS and the consequent hemodynamic changes during LT. 3-Dimensional computed tomography and Doppler ultrasonography were used to evaluate SRS and portal vein blood flow volume (PFV).

A total of 22 recipients had large SRS including 13 with PFV <85 ml/min/100 g (ligation group) and 9 with PFV ≥85 ml/min/100 g (no ligation group). The diameter of SRS was significantly larger in the ligation group than in the non-ligation group (22.92 ± 4.18 vs. 16.24 ± 3.60 mm; p = 0.0009). In all ligation patients, the SRS was easily identified and isolated, it was located just below the distal pancreas and beside the inferior mesenteric vein. PV flow increased significantly from 68.74 ± 8.77 to 116.80 ± 16.50 ml/min/100 g (p < 0.0001) after ligation; this was followed by a reduction in peak systolic velocity of the hepatic artery from 58.17 ± 14.87 to 46.67 ± 13.28 cm/s (p = 0.0013).

Direct ligation of large SRS was an effective and safe surgical procedure to overcome the problem of portal hypoperfusion during LT.

• hemodynamic consequences
• liver transplantation
• portal blood flow volume
• portal vein thrombus
• spontaneous splenorenal shunts

• Liver transplantation
• Portal hypertension
• Portal vein
• Splenectomy
• Spontaneous portosystemic shunts

• Esophageal and Gastric Varices/complications
• Esophageal and Gastric Varices/etiology
• Hepatic Encephalopathy/diagnostic imaging
• Hepatic Encephalopathy/etiology
• Humans
• Liver Cirrhosis/complications
• Liver Cirrhosis/diagnostic imaging
• Portasystemic Shunt, Transjugular Intrahepatic/adverse effects
• Tomography, X-Ray Computed/methods

The predictive value of a subjective difficulty scale (DS) after surgical procedures is unknown. The objective of this study was to evaluate the prognostic value of a DS after liver transplantation (LT) and to identify predictors of difficulty. Surgeons prospectively evaluated the difficulty of 441 consecutive liver transplantations from donation after brain death at the end of the surgery by using a DS from 0 to 10 (“the easiest to the hardest you can imagine”). DS was associated with severe morbidity. The risk of graft loss at 1 year remained unchanged from 0 to 6 but increased beyond 6. Graft survival and patient survival of group with DS 7–10 was significantly impaired compared to groups with DS: 0–3 or DS: 4–6 but were significantly impaired for the group with DS: 7–10. Independent predictors of difficult LT (DS ≥ 7) were annular segment 1, transjugular intrahepatic portosystemic shunt, retransplantation beyond 30 days, portal vein thrombosis, and ascites. Of them, ascites was a borderline non-significant covariate (p = .04). Vascular complications occurred more often after difficult LT (20.5% vs. 5.9%), whereas there was no difference in the other types of complications. DS can be used to tailor monitoring and anticipate early complications. External validation is needed.

• difficulty
• liver transplantation
• retransplantation
• subjective difficulty
• technical difficulty

• diffuse splanchnic vein thrombosis
• kidney function
• liver transplant
• portal vein thrombosis
• reno-portal anastomosis

• TIPS
• collaterals
• embolization
• hepatic encephalopathy
• liver transplant
• portal hypertension
• review

• Anastomosis
• Atretic portal vein
• Liver transplantation

• Anastomosis, Surgical/methods
• Atrophy
• End Stage Liver Disease/etiology
• End Stage Liver Disease/surgery
• Esophageal and Gastric Varices/surgery
• Female
• Humans
• Hypertension, Portal/etiology
• Liver Transplantation/methods
• Living Donors
• Male
• Middle Aged
• Portal Vein/pathology
• Portal Vein/surgery
• Vascular Grafting
• Vascular Surgical Procedures/methods
• Young Adult

Portal vein thrombosis (PVT) is currently not considered a contraindication for liver transplantation (LT), but diffuse or complicated PVT remains a major surgical challenge. Here, we review the prevalence, natural course and current grading systems of PVT and propose a tailored classification of PVT in the setting of LT. PVT in liver transplant recipients is classified into three types, corresponding to three portal reconstruction strategies: Anatomical, physiological and non-physiological. Type I PVT can be removed via low dissection of the portal vein (PV) or thrombectomy; porto-portal anastomosis is then performed with or without an interposed vascular graft. Physiological reconstruction used for type II PVT includes vascular interposition between mesenteric veins and PV, collateral-PV and splenic vein-PV anastomosis. Non-physiological reconstruction used for type III PVT includes cavoportal hemitransposition, renoportal anastomosis, portal vein arterialization and multivisceral transplantation. All portal reconstruction techniques were reviewed. This tailored classification system stratifies PVT patients by surgical complexity, risk of postoperative complications and long-term survival. We advocate using the tailored classification for PVT grading before LT, which will urge transplant surgeons to make a better preoperative planning and pay more attention to all potential strategies for portal reconstruction. Further verification in a large-sample cohort study is needed.

• Portal vein thrombosis
• Liver transplantation
• Portal reconstruction
• Grading
• Anatomical
• Physiological
• Non-physiological

• Allografts/blood supply
• Anastomosis, Surgical
• Dissection/adverse effects
• Humans
• Liver/blood supply
• Liver Transplantation/adverse effects
• Patient Care Planning
• Portal Vein/pathology
• Portal Vein/surgery
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Preoperative Period
• Prevalence
• Thrombectomy/adverse effects
• Venous Thrombosis/classification
• Venous Thrombosis/complications
• Venous Thrombosis/epidemiology
• Venous Thrombosis/surgery

• classification
• complex portal vein thrombosis
• liver transplantation
• non-malignant portal vein thrombosis
• surgical decisiveness

• liver transplant
• long term outcome
• portal vein thrombosis
• renoportal anastomosis
• short term outcome

Cirrhosis and portal hypertension can lead to the formation of a spontaneous splenorenal shunt (SSRS) that may divert portal blood flow to the systemic circulation and reduce hepatic perfusion. Our aims were to evaluate SSRSs as an independent prognostic marker for mortality in patients with decompensated cirrhosis and the influence of SSRSs on liver transplantation (LT) outcomes. We retrospectively analyzed adult patients with decompensated cirrhosis undergoing LT evaluation from January 2001 to February 2016 at a large U.S. center. All patients underwent liver cross‐sectional imaging within 6 months of evaluation, and images were reviewed by two radiologists. Clinical variables were obtained by electronic health record review. The cohort was followed until death or receipt of LT, and the subset receiving LT was followed for death after LT or graft failure. Survival data were analyzed using multivariable competing risk and Cox proportional‐hazards regression models. An SSRS was identified in 173 (23%) of 741 included patients. Patients with an SSRS more often had portal vein thrombosis and less often had ascites (P < 0.01). An SSRS was independently associated with a nonsignificant trend for reduced mortality (adjusted subhazard ratio, 0.81; Gray's test P = 0.08) but had no association with receipt of LT (adjusted subhazard ratio, 1.02; Gray's test P = 0.99). Post‐LT outcomes did not differ according to SSRS for either death (hazard ratio, 0.85; log‐rank P = 0.71) or graft failure (hazard ratio, 0.71; log‐rank P = 0.43). Conclusion: Presence of an SSRS does not predict mortality in patients with decompensated cirrhosis or in LT recipients. (Hepatology Communications 2018;2:437‐444)

In the context of cirrhosis, portal vein thrombosis (PVT) is present in 2.1% to 26% of patients. PVT is no longer considered an absolute contraindication for liver transplantation, and nowadays, surgical strategies depend on the extent of PVT. Complete PVT is associated with higher morbidity rates and poor prognosis, while comparable long-term outcomes can be achieved as long as physiological portal inflow is restored.

We report our experience with a 45-year-old patient undergoing liver transplant with a PVT (stage III-b). To restore portal vein inflow to the liver, an extra-anatomic jump graft from the right colic vein with donor iliac vein interposition was constructed.

The patient recovered well, with a progressive improvement of the general conditions, and was finally discharged on p.o.d. 14. No anastomotic defects were found at the postoperative CT scan 10 months after the surgery.

Our technical innovation represents a valid and safe alternative to the cavoportal hemitransposition, providing a proper flow restoration and reproducing a physiological setting, while avoiding the complications related to the cavoportal shunt. We believe that the reconstitution of liver portal inflow should be obtained with the most physiological approach possible and considering long-term liver function.

Patient: Male, 51

Final Diagnosis: Liver cirrhosis by hepatitis virus C and hepatocellular carcinoma

Symptoms: Ascites

Medication: —

Clinical Procedure: Liver transplantantion

Specialty: Surgery

肝硬化可以导致门静脉高压, 并通过形成侧支循环和自发性分流来降低门静脉压力, 其中以食管、胃静脉曲张及胃肾、脾肾分流最多见. 因为随机对照研究的缺乏, 规范化治疗胃底静脉曲张破裂出血的临床方案仍未能统一, 现最有效且常用的方法是内镜下组织胶黏合剂注射, 但对于合并自发性分流者可导致异位栓塞等严重并发症; 自发性分流道的存在也影响着胃底曲张静脉治疗方案的选择. 本文就近年来对自发性分流道的研究及其对胃底曲张静脉内镜治疗方案的选择及疗效作一简要综述.

• 肝硬化
• 胃静脉曲张
• 胃肾分流
• 脾肾分流
• 内镜治疗

Due to the complexity of the surgical procedure portal vein thrombosis (PVT) has long been considered an absolute contraindication to liver transplantation (LT). The presence of a large splenorenal shunt (SRS) could make portal anastomosis a valid option.

We report the case of a 37-year-old female patient with Grade III PVT and a large SRS, who underwent orthotopic LT. Liver was implanted using a 1992-Belghiti piggyback technique and portal anastomosis was performed using the large spleno-renal shunt. We observed good graft reperfusion and postoperative Doppler ultrasound showed normal portal vein flow. She was discharged on postoperative day 7, with an excellent graft function. At six months follow-up, patient is alive with normal hepatic vascularization.

Due to paucity of reports, there is currently no consensus on the indication to LT and/or surgical technique. In the present case, once the transplant benefit was evaluated, the Grade III PVT was not considered a contraindication to LT.

The presence of a Grade III PVT associated with a large SRS should not be considered a contraindication for LT, and the use of the shunt vein should be considered a feasible option to perform portal anastomosis.

•

The Yerdel III–IV portal vein trombosis should not be considered an absolute controindication to liver transplantation

• CT, computed tomography scan
• Case report
• ICU, Intensive Care Unit
• LRV, left renal vein
• LT, liver transplantation
• Liver transplantation
• PVT, portal vein thrombosis
• Portal vein thrombosis
• SRS, spleno-renal shunt
• Spleno-renal shunt