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Naidu SG, Alzubaidi SJ, Patel IJ, Iwuchukwu C, Zurcher KS, Malik DG, Knuttinen MG, Kriegshauser JS, Wallace AL, Katariya NN, Mathur AK, Oklu R. Interventional Radiology Management of Adult Liver Transplant Complications. Radiographics 2022; 42:1705-1723. [DOI: 10.1148/rg.220011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Sailendra G. Naidu
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Sadeer J. Alzubaidi
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Indravadan J. Patel
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Chris Iwuchukwu
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Kenneth S. Zurcher
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Dania G. Malik
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Martha-Gracia Knuttinen
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - J. Scott Kriegshauser
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Alex L. Wallace
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Nitin N. Katariya
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Amit K. Mathur
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Rahmi Oklu
- From the Division of Interventional Radiology (S.G.N., S.J.A., I.J.P., C.I., M.G.K., J.S.K., A.L.W., R.O.), Department of Radiology (K.S.Z., D.G.M.), and Division of Transplant Surgery (N.N.K., A.K.M.), Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054
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Massarollo PCB, Coelho FF, Brescia MDG, Sandoli Baía CE, Lallée MP, Dias de Almeida M, Salzedas-Netto AA, Coppini AZ, Massarollo DB, Mies S. Long-term Outcome of a Modified Piggyback Liver Transplantation Technique Using the Recipient's Right and Middle Hepatic Veins. Transplant Proc 2020; 52:1308-1311. [PMID: 32247596 DOI: 10.1016/j.transproceed.2020.02.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/07/2020] [Indexed: 11/18/2022]
Abstract
In early piggyback liver transplantation (LT) descriptions, the common stump of the middle and left hepatic veins (ML) was used for upper caval anastomosis. In this variant, stenosis or kinking of graft venous outflow path was frequent. Over time, most authors adopted the use of the recipient's right, middle, and left hepatic veins (RML) or a side-to-side anastomosis (SS) between the graft's and recipient's inferior vena cava (IVC). Nonetheless, partial IVC clamping required in RML and SS can reduce IVC flow. Since 1998, we incorporated a modified piggyback procedure using the recipient's right and middle hepatic veins (RM) to simultaneously achieve better preservation of IVC flow and a wide and well-positioned anastomosis. OBJECTIVE The aim of this study is to describe the RM method and to compare this technique with other standard variants of piggyback LT. METHOD We conducted a retrospective analysis of 477 piggyback LTs classified in 4 groups: ML (n = 102); RM (n = 171); RML (n = 150); and SS (n = 54). RESULTS The incidence of venous outflow block was 3.9% (4/102) in ML, 2.3% (4/171) in RM, 0% (0/150) in RML, and 3.7% (2/54) in SS (P = .049). On Bonferroni multiple comparison analysis, no statistically significant paired difference was identified. Results showed that 1-, 3-, 5-, and 10-year patient survival was 76%, 67%, 63%, and 51% in the ML group; 80%, 71%, 68%, and 62% in the RM group; 77%, 75%, 70%, and 64% in the RML group; and 76%, 76%, 76%, and 70% in the SS group, respectively (P = .193). CONCLUSION The RM modified piggyback LT technique is feasible and safe.
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Affiliation(s)
| | | | | | | | - Margareth Pauli Lallée
- LIM-02, Department of Surgery, University of São Paulo Medical School, São Paulo, Brazil; Hospital de Transplantes Euryclides de Jesus Zerbini, São Paulo, Brazil
| | | | - Alcides Augusto Salzedas-Netto
- Transplant Service, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil; Department of Surgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Adriana Zuolo Coppini
- Transplant Service, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Daniel Braga Massarollo
- Transplant Service, Department of Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Sérgio Mies
- LIM-02, Department of Surgery, University of São Paulo Medical School, São Paulo, Brazil
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Mourad M, Mabrut JY, Chellakhi M, Lesurtel M, Prevost C, Ducerf C, Rode A, Merle P, Mornex F, Mohkam K. Neoadjuvant conformal radiotherapy before liver transplantation for hepatocellular carcinoma: a propensity score matched analysis of postoperative morbidity and oncological results. Future Oncol 2019; 15:2517-2530. [DOI: 10.2217/fon-2019-0127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Aim: To assess neoadjuvant conformal radiotherapy (CRT) before orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) not suitable for standard locoregional treatments. Methods: Patients undergoing OLT for HCC with or without prior CRT were compared using 1:3 propensity score matching. Results: After propensity score matching, 23 patients with CRT were compared with 66 control subjects. Severe morbidity rate was 34.8 versus 24.2% in the CRT and non-CRT groups (p = 0.289). Complete pathological response was observed in 47.8% of CRT-targeted nodules. The 1-/3-/5-year disease-free survivals were 77.3, 77.3 and 68.7% in the CRT group versus 85.4, 68.0 and 61.7% in the non-CRT group (p = 0.829). Conclusion: Conformal radiotherapy represents a satisfactory neoadjuvant therapy for OLT candidates not suitable for standard HCC locoregional therapies.
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Affiliation(s)
- Mohamed Mourad
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
- Ecole Doctorale Biologie Moléculaire Intégrative et Cellulaire (BMIC), Claude Bernard Lyon 1 University, Lyon, France
- Department of General & Digestive Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Jean-Yves Mabrut
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
| | - Madiha Chellakhi
- Department of Oncology & Radiotherapy, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Mickaël Lesurtel
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
| | - Célia Prevost
- Department of Oncology & Radiotherapy, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Christian Ducerf
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
| | - Agnès Rode
- Department of Radiology, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Philippe Merle
- Department of Hepatology, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Françoise Mornex
- Department of Oncology & Radiotherapy, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Kayvan Mohkam
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unit U1052, Cancer Research Center of Lyon, Lyon, France
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Golse N, Mohkam K, Rode A, Pradat P, Ducerf C, Mabrut JY. Splenectomy during whole liver transplantation: a morbid procedure which does not adversely impact long-term survival. HPB (Oxford) 2017; 19:498-507. [PMID: 28233673 DOI: 10.1016/j.hpb.2017.01.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 12/16/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Indications for splenectomy (SP) during whole liver transplantation (LT) remain controversial and SP is often avoided because of common complications. We aimed to evaluate specific complications of these combined procedures. METHODS Data were retrospectively analysed. Splenectomy was performed in patients with splenorenal shunt and/or splenic artery aneurysms or hypersplenism. Patients undergoing simultaneous transplantation and splenectomy (LTSP group) were matched to a non-splenectomy group (LT group). RESULTS Between 1994 and 2013, we included 47 and 94 patients in LTSP and LT groups, respectively. The LTSP patients had a higher rate of pre-LT portal vein thrombosis (PVT). The LTSP group had a longer operative time and greater blood loss. Mean follow-up was 101 months and 5-year survivals were identical (LTSP 85% vs LT 88%, p = 0.831). Hospital morbidity and rejection incidence were comparable, whereas de novo PVT (34% vs 2%, p < 0.0001) and infection (47% vs 25%, p = 0.014) rates were higher after SP. CONCLUSION Splenectomy during LT is technically demanding and exposes recipients to a higher thrombosis rate, therefore portal vein patency must be specifically assessed postoperatively. In selected recipients, SP can be performed without increased mortality but at the price of worsening outcome as evidenced by greater risk of infection and PVT.
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Affiliation(s)
- Nicolas Golse
- Croix-Rousse Hospital, Digestive Surgery and Liver Transplant Department, Hospices Civils de Lyon, Lyon, France.
| | - Kayvan Mohkam
- Croix-Rousse Hospital, Digestive Surgery and Liver Transplant Department, Hospices Civils de Lyon, Lyon, France.
| | - Agnès Rode
- Croix-Rousse Hospital, Radiology Department, Hospices Civils de Lyon, Lyon, France.
| | - Pierre Pradat
- Department of Hepatology, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France; INSERM U1052, CRCL, Lyon, France; Centre for Clinical Research, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France.
| | - Christian Ducerf
- Croix-Rousse Hospital, Digestive Surgery and Liver Transplant Department, Hospices Civils de Lyon, Lyon, France.
| | - Jean-Yves Mabrut
- Croix-Rousse Hospital, Digestive Surgery and Liver Transplant Department, Hospices Civils de Lyon, Lyon, France.
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Jang JY, Jeon UB, Park JH, Kim TU, Lee JW, Chu CW, Ryu JH. Efficacy and patency of primary stenting for hepatic venous outflow obstruction after living donor liver transplantation. Acta Radiol 2017; 58:34-40. [PMID: 27012279 DOI: 10.1177/0284185116637247] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 02/07/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hepatic venous outflow is important for graft survival in living donor liver transplantation (LDLT). If hepatic venous outflow obstruction occurs, hepatic vein stenting is considered to restore the patency. PURPOSE To retrospectively evaluate the efficacy and patency of primary hepatic vein stenting for hepatic venous outflow obstruction (HVOO) after LDLT. MATERIAL AND METHODS Percutaneous interventions, including hepatic vein stent placement with or without balloon angioplasty, were performed in 21 patients who had undergone LDLT and had HVOO confirmed through hepatic venography or manometry, including the patients who had a structural abnormality. Two stents each were inserted in four patients; therefore, the total number of treated anastomoses was 25. Technical success, patency rates, and pressure gradients between hepatic veins and the right atrium were evaluated in 19 patients each. RESULTS Technical success was achieved in 25 of 26 vessels (96%). The mean interval between operation and stenting was 43 days. After the procedure, the follow-up period was a mean 530 days. The mean pressure gradient decreased from 8.5 mmHg to 2.1 mmHg after treatment (P < 0.01). The patency rates of the 25 vessels were 80% at 1, 2, and 3 years after stent placement. However, middle hepatic vein stenting revealed a low patency rate (all were 36%). Three of seven stents (43%) in the middle hepatic vein occluded during follow-up. CONCLUSION Percutaneous primary hepatic vein stent replacement is an effective treatment for HVOO after LDLT.
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Affiliation(s)
- Joo Yeon Jang
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Ung Bae Jeon
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Jung Hwan Park
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Tae Un Kim
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Jun Woo Lee
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Chong Woo Chu
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Je Ho Ryu
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
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Pitchaimuthu M, Roll GR, Zia Z, Olliff S, Mehrzad H, Hodson J, Gunson BK, Perera MTPR, Isaac JR, Muiesan P, Mirza DF, Mergental H. Long-term follow-up after endovascular treatment of hepatic venous outflow obstruction following liver transplantation. Transpl Int 2016; 29:1106-16. [PMID: 27371935 DOI: 10.1111/tri.12817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/07/2016] [Accepted: 06/28/2016] [Indexed: 01/10/2023]
Affiliation(s)
- Maheswaran Pitchaimuthu
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - Garrett R. Roll
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
- Division of Transplant Surgery; University of California; San Francisco CA USA
| | - Zergham Zia
- Department of Radiology; Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - Simon Olliff
- Department of Radiology; Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - Homoyoon Mehrzad
- Department of Radiology; Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - James Hodson
- National Institute for Health Research Birmingham; Liver Biomedical Research Unit and Centre for Liver Research; Institute of Immunology and Immunotherapy; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
| | - Bridget K. Gunson
- National Institute for Health Research Birmingham; Liver Biomedical Research Unit and Centre for Liver Research; Institute of Immunology and Immunotherapy; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
| | - M. Thamara P. R. Perera
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - John R. Isaac
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - Paolo Muiesan
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - Darius F. Mirza
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
- National Institute for Health Research Birmingham; Liver Biomedical Research Unit and Centre for Liver Research; Institute of Immunology and Immunotherapy; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
| | - Hynek Mergental
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
- National Institute for Health Research Birmingham; Liver Biomedical Research Unit and Centre for Liver Research; Institute of Immunology and Immunotherapy; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
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Navez J, Golse N, Bancel B, Rode A, Ducerf C, Mezoughi S, Mohkam K, Mabrut JY. Traumatic biliary neuroma after orthotopic liver transplantation: a possible cause of “unexplained” anastomotic biliary stricture. Clin Transplant 2016; 30:1366-1369. [DOI: 10.1111/ctr.12802] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Julie Navez
- Department of General Surgery and Liver Transplantation; Hospices Civils de Lyon; Croix-Rousse University Hospital; Lyon France
| | - Nicolas Golse
- Department of General Surgery and Liver Transplantation; Hospices Civils de Lyon; Croix-Rousse University Hospital; Lyon France
| | - Brigitte Bancel
- Department of Pathology; Hospices Civils de Lyon; Croix-Rousse University Hospital; Lyon France
| | - Agnès Rode
- Department of Radiology; Hospices Civils de Lyon; Croix-Rousse University Hospital; Lyon France
| | - Christian Ducerf
- Department of General Surgery and Liver Transplantation; Hospices Civils de Lyon; Croix-Rousse University Hospital; Lyon France
| | - Salim Mezoughi
- Department of General Surgery and Liver Transplantation; Hospices Civils de Lyon; Croix-Rousse University Hospital; Lyon France
| | - Kayvan Mohkam
- Department of General Surgery and Liver Transplantation; Hospices Civils de Lyon; Croix-Rousse University Hospital; Lyon France
- Université Claude Bernard Lyon 1; EMR 3738, EDISS 205 Lyon France
| | - Jean-Yves Mabrut
- Department of General Surgery and Liver Transplantation; Hospices Civils de Lyon; Croix-Rousse University Hospital; Lyon France
- Université Claude Bernard Lyon 1; EMR 3738, EDISS 205 Lyon France
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8
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Mohkam K, Golse N, Bonal M, Ledochowski S, Rode A, Selmaji IE, Merle P, Ducerf C, Mornex F, Mabrut JY. Conformal radiotherapy as a bridge to liver transplantation for hepatocellular carcinoma: is it safe? Future Oncol 2016; 12:1577-86. [DOI: 10.2217/fon-2016-0083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aim: To report a preliminary experience of conformal radiotherapy (CRT) as bridge to orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC). Methods: Data of 12 patients undergoing CRT for HCC followed by OLT between 2012 and 2014 were reviewed. Results: CRT was used in a neoadjuvant or downstaging setting in nine and three patients, respectively. No radiation-related systemic toxicity was observed. Median blood loss and operating time were 1450 ml (600–4000) and 420 min (240–510), respectively. Four patients had diaphragmatic injury. Complete histological response was observed in six patients, and partial response in five. Seven patients developed severe postoperative morbidity including five anastomosis-related complications and one death. Conclusion: CRT for HCC provides satisfactory histological response but may compromise OLT safety.
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Affiliation(s)
- Kayvan Mohkam
- Department of General Surgery & Liver Transplant, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
- Equipe Mixte de Recherche 3738, Ecole Doctorale EDISS 205, Université Claude Bernard Lyon 1, Lyon, France
| | - Nicolas Golse
- Department of General Surgery & Liver Transplant, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Mathieu Bonal
- Department of General Surgery & Liver Transplant, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Stanislas Ledochowski
- Intensive Care Unit, Hospices Civils de Lyon, Lyon-Sud University Hospital, Pierre-Bénite, France
| | - Agnès Rode
- Department of Radiology, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Imad E Selmaji
- Department of Radiation Oncology, Hospices Civils de Lyon, Lyon-Sud University Hospital, Pierre-Bénite, France
| | - Philippe Merle
- Department of Hepatology, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Christian Ducerf
- Department of General Surgery & Liver Transplant, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Françoise Mornex
- Equipe Mixte de Recherche 3738, Ecole Doctorale EDISS 205, Université Claude Bernard Lyon 1, Lyon, France
- Department of Radiation Oncology, Hospices Civils de Lyon, Lyon-Sud University Hospital, Pierre-Bénite, France
| | - Jean-Yves Mabrut
- Department of General Surgery & Liver Transplant, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
- Equipe Mixte de Recherche 3738, Ecole Doctorale EDISS 205, Université Claude Bernard Lyon 1, Lyon, France
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Liver transplantation of a graft with a left hepatic vein draining directly into the right atrium. J Visc Surg 2016; 153:315-6. [PMID: 27318586 DOI: 10.1016/j.jviscsurg.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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10
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Sarwar A, Ahn E, Brennan I, Brook OR, Faintuch S, Malik R, Khwaja K, Ahmed M. Utility of liver biopsy in predicting clinical outcomes after percutaneous angioplasty for hepatic venous obstruction in liver transplant patients. World J Hepatol 2015; 7:1884-1893. [PMID: 26207170 PMCID: PMC4506946 DOI: 10.4254/wjh.v7.i14.1884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 06/16/2015] [Accepted: 07/14/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine utility of transplant liver biopsy in evaluating efficacy of percutaneous transluminal angioplasty (PTA) for hepatic venous obstruction (HVOO).
METHODS: Adult liver transplant patients treated with PTA for HVOO (2003-2013) at a single institution were reviewed for pre/post-PTA imaging findings, manometry (gradient with right atrium), presence of HVOO on pre-PTA and post-PTA early and late biopsy (EB and LB, < or > 60 d after PTA), and clinical outcome, defined as good (no clinical issues, non-HVOO-related death) or poor (surgical correction, recurrent HVOO, or HVOO-related death).
RESULTS: Fifteen patients meeting inclusion criteria underwent 21 PTA, 658 ± 1293 d after transplant. In procedures with pre-PTA biopsy (n = 19), no difference was seen between pre-PTA gradient in 13/19 procedures with HVOO on biopsy and 6/19 procedures without HVOO (8 ± 2.4 mmHg vs 6.8 ± 4.3 mmHg; P = 0.35). Post-PTA, 10/21 livers had EB (29 ± 21 d) and 9/21 livers had LB (153 ± 81 d). On clinical follow-up (392 ± 773 d), HVOO on LB resulted in poor outcomes and absence of HVOO on LB resulted good outcomes. Patients with HVOO on EB (3/7 good, 4/7 poor) and no HVOO on EB (2/3 good, 1/3 poor) had mixed outcomes.
CONCLUSION: Negative liver biopsy greater than 60 d after PTA accurately identifies patients with good clinical outcomes.
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Surgical Management of Large Spontaneous Portosystemic Splenorenal Shunts During Liver Transplantation: Splenectomy or Left Renal Vein Ligation? Transplant Proc 2015; 47:1866-76. [DOI: 10.1016/j.transproceed.2015.06.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 06/05/2015] [Accepted: 06/16/2015] [Indexed: 12/13/2022]
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Brescia MDG, Massarollo PCB, Imakuma ES, Mies S. Prospective Randomized Trial Comparing Hepatic Venous Outflow and Renal Function after Conventional versus Piggyback Liver Transplantation. PLoS One 2015; 10:e0129923. [PMID: 26115520 PMCID: PMC4482688 DOI: 10.1371/journal.pone.0129923] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 05/11/2015] [Indexed: 12/27/2022] Open
Abstract
Background This randomized prospective clinical trial compared the hepatic venous outflow drainage and renal function after conventional with venovenous bypass (n = 15) or piggyback (n = 17) liver transplantation. Methods Free hepatic vein pressure (FHVP) and central venous pressure (CVP) measurements were performed after graft reperfusion. Postoperative serum creatinine (Cr) was measured daily on the first week and on the 14th, 21st and 28th postoperative days (PO). The prevalence of acute renal failure (ARF) up to the 28th PO was analyzed by RIFLE-AKIN criteria. A Generalized Estimating Equation (GEE) approach was used for comparison of longitudinal measurements of renal function. Results FHVP-CVP gradient > 3 mm Hg was observed in 26.7% (4/15) of the patients in the conventional group and in 17.6% (3/17) in the piggyback group (p = 0.68). Median FHVP-CVP gradient was 2 mm Hg (0–8 mmHg) vs. 3 mm Hg (0–7 mm Hg) in conventional and piggyback groups, respectively (p = 0.73). There is no statistically significant difference between the conventional (1/15) and the piggyback (2/17) groups regarding massive ascites development (p = 1.00). GEE estimated marginal mean for Cr was significantly higher in conventional than in piggyback group (2.14 ± 0.26 vs. 1.47 ± 0.15 mg/dL; p = 0.02). The conventional method presented a higher prevalence of severe ARF during the first 28 PO days (OR = 3.207; 95% CI, 1.010 to 10.179; p = 0.048). Conclusion Patients submitted to liver transplantation using conventional or piggyback methods present similar results regarding venous outflow drainage of the graft. Conventional with venovenous bypass technique significantly increases the harm of postoperative renal dysfunction. Trial Registration ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT01707810
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Affiliation(s)
- Marília D’Elboux Guimarães Brescia
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- * E-mail:
| | - Paulo Celso Bosco Massarollo
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ernesto Sasaki Imakuma
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Sérgio Mies
- Laboratório de Anatomia Médico-Cirúrgica (LIM-02), Departamento de Cirurgia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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13
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Beal EW, Bennett SC, Whitson BA, Elkhammas EA, Henry ML, Black SM. Caval reconstruction techniques in orthotopic liver transplantation. World J Surg Proced 2015; 5:41-57. [DOI: 10.5412/wjsp.v5.i1.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/28/2015] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
There are several caval reconstruction techniques currently in use for orthotopic liver transplantation. These include caval replacement or the conventional technique, performed with or without venovenous bypass, piggyback technique with anastomosis with two or three hepatic veins with or without cavotomy and modifications of the piggyback technique including end-to-side and side-to-side cavocaval anastomosis. There are few randomized controlled trials comparing the use of these techniques and our knowledge of their comparability is based on a few multi- and many single-center retrospective and prospective reviews. Although there are advantages and disadvantages for each technique, it is advisable that the surgeon perform the technique with which they have the most the experience and at which they are the most skilled as excellent outcomes can be obtained with any of the caval reconstruction options discussed.
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Hepatic venous outflow obstruction after transplantation: Outcomes for treatment with self-expanding stents. RADIOLOGIA 2015. [DOI: 10.1016/j.rxeng.2013.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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15
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Balloon venoplasty for liver failure due to stenosis of the left hepatic vein after right tri-segmentectomy. Int Surg 2014; 98:160-3. [PMID: 23701153 DOI: 10.9738/intsurg-d-12-00032.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
A 41-year-old male patient with hepatitis B underwent right tri-segmentectomy and total caudate lobectomy for a huge hepatocellular carcinoma associated with complete occlusion of the inferior vena cava with thrombosis of the infrahepatic inferior vena cava due to tumor compression. Five months later, he was readmitted for ascites and hyperbilirubinemia. Venography revealed stenosis and tortuosity of the left hepatic vein and the inferior vena cava, for which balloon angioplasty of the left hepatic vein and the inferior vena cava was performed using an 8-mm and 10-mm balloon, respectively. The left hepatic venous pressure decreased from 65 mmHg to 25 mmHg after dilatation. The patient made a satisfactory recovery thereafter and remains well with normal liver functions and without ascites. Balloon angioplasty may be useful for liver failure due to hepatic vein stenosis after hepatic resection.
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16
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Viteri-Ramírez G, Alonso-Burgos A, Simon-Yarza I, Rotellar F, Herrero JI, Bilbao JI. Hepatic venous outflow obstruction after transplantation: outcomes for treatment with self-expanding stents. RADIOLOGIA 2014; 57:56-65. [PMID: 24784003 DOI: 10.1016/j.rx.2013.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 08/02/2013] [Accepted: 09/07/2013] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To evaluate the safety and patency of self-expanding stents to treat hepatic venous outflow obstruction after orthotopic liver transplantation. To evaluate differences in the response between patients with early obstruction and patients with late obstruction. MATERIAL AND METHODS This is a retrospective analysis of 16 patients with hepatic venous outflow obstruction after liver transplantation treated with stents (1996-2011). Follow-up included venography/manometry, ultrasonography, CT, and laboratory tests. We did a descriptive statistical analysis of the survival of patients and stents, technical and clinical success of the procedure, recurrence of obstruction, and complications of the procedure. We also did an inferential statistical analysis of the differences between patients with early and late obstruction. RESULTS The mean follow-up period was 3.34 years (21-5,331 days). The technical success rate was 93.7%, and the clinical success rate was 81.2%. The rate of complications was 25%. The survival rates were 87.5% for patients and 92.5% for stents. The rate of recurrence was 12.5%. The rate of primary patency was 0.96 (95% CI 0.91-1) at 3 months, 0.96 (95% CI 0.91-1) at 6 months, 0.87 (95% CI 0.73-1) at 12 months, and 0.87 (95% CI 0.73-1) at 60 months. There were no significant differences between patients with early and late obstruction, although there was a trend toward higher rates of primary patency in patients with early obstruction (P=.091). CONCLUSIONS Treating hepatic venous outflow obstruction after orthotopic transplantation with self-expanding stents is effective, durable, and effective. There are no significant differences between patients with early obstruction and those with late obstruction.
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Affiliation(s)
- G Viteri-Ramírez
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España.
| | - A Alonso-Burgos
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España; Servicio de Radiología, Fundación Jiménez Díaz, Madrid, España
| | - I Simon-Yarza
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España
| | - F Rotellar
- Servicio de Cirugía General y Abdominal, Clínica Universidad de Navarra, Pamplona, España
| | - J I Herrero
- Unidad de Hepatología, Clínica Universidad de Navarra, Pamplona, España
| | - J I Bilbao
- Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, España
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17
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Ferro C, Andorno E, Guastavino A, Rossi UG, Seitun S, Bovio G, Valente U. Endovascular treatment with primary stenting of inferior cava vein torsion following orthotopic liver transplantation with modified piggyback technique. Radiol Med 2013; 119:183-8. [PMID: 24356944 DOI: 10.1007/s11547-013-0325-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 10/02/2012] [Indexed: 12/29/2022]
Abstract
PURPOSE This study was undertaken to evaluate primary stenting in patients with inferior vena cava torsion after orthotopic liver transplantation performed with modified piggyback technique. MATERIALS AND METHODS From November 2003 to October 2010, six patients developed clinical, laboratory and imaging findings suggestive of caval stenosis, after a mean period of 21 days from an orthotopic liver transplantation performed with modified piggyback technique. Vena cavography showed stenosis due to torsion of the inferior vena cava at the anastomoses and a significant caval venous pressure gradient. All patients were treated with primary stenting followed by in-stent angioplasty in three cases. RESULTS In all patients, the stents were successfully positioned at the caval anastomosis and the venous gradient pressure fell from a mean value of 10 to 2 mmHg. Signs and symptoms resolved in all six patients. One patient died 3 months after stent placement due to biliary complications. No evidence of recurrence or complications was noted during the follow-up (mean 49 months). CONCLUSIONS Primary stenting of inferior vena cava stenosis due to torsion of the anastomoses in patients receiving orthotopic liver transplantation with modified piggyback technique is a safe, effective and durable treatment.
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Affiliation(s)
- Carlo Ferro
- Dipartimento di Radiologia e Radiologia Interventistica, IRCCS Azienda Ospedaliera ed Universitaria San Martino, IST-Istituto Nazionale per la Ricerca sul Cancro, Monoblocco 1-Fondi, Largo Rosanna Benzi 10, 16132, Genoa, Italy,
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18
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Ettorre GM, Santoro R, Lepiane P, Laurenzi A, Colasanti M, Meniconi RL, Colace L, Antonini M, Vennarecci G. Hanging of the hepatic veins septa: a safe control prior and during outflow anastomosis in liver transplantation. Transplant Proc 2013; 45:3314-5. [PMID: 24182808 DOI: 10.1016/j.transproceed.2013.07.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 07/09/2013] [Indexed: 11/17/2022]
Abstract
Inferior vena cava (IVC) preservation during orthotopic liver transplantation (OLT) is known as the "piggyback" technique. The end-to-side anastomosis is constructed between the graft's IVC and recipient's hepatic veins using a Satinsky side clamp applied in a transverse position. To stabilize the large Satinsky clamp and preserve a sufficient vascular stump after hepatectomy and before graft implantation, we propose a technical innovation consisting of hanging the septa between the left and middle hepatic vein and between the middle and right hepatic vein using 2 tapes. This technique showed some advantages when performing the caval outflow anastomosis, representing a further technical refinement of the piggyback end-to-side technique for the implantation on the 3 hepatic veins. From November 2001 to September 2012, we performed 272 consecutive OLT at our institution with the piggyback technique using the hanging of the hepatic veins septa in all cases. In conclusion, the hanging of the 3 hepatic veins septa presented in this study represents a simple, safe and reproducible technique for the outflow anastomosis using the piggyback technique.
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Affiliation(s)
- G M Ettorre
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital Rome, Italy.
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19
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Ming YZ, Niu Y, Shao MJ, She XG, Ye QF. Hepatic veins anatomy and piggy-back liver transplantation. Hepatobiliary Pancreat Dis Int 2012; 11:429-33. [PMID: 22893472 DOI: 10.1016/s1499-3872(12)60203-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The piggy-back caval anastomosis technique is widely used in orthotopic liver transplantation although it carries an increased risk of complications, including outflow obstruction and Budd-Chiari syndrome. The aim of this study is to clarify the anatomy and variations of hepatic veins (HVs) draining into the inferior vena cava (IVC), and to classify the surgical techniques of piggy-back liver transplantation (PBLT) based on the anatomy of HVs which can reduce the occurrence of complications. METHODS PBLT was performed in 248 consecutive cases at our hospital from January 2004 to August 2011. The anatomy of recipients' HVs was determined when removing the native diseased livers. Both anatomy of HVs and short HVs draining into the IVC were recorded. These data were collected and analyzed. RESULTS We classified anatomic variations of HVs in the 248 livers into five types according to the way of drainage into the IVC: type I (trunk type of left and middle HVs), 142 (57.3%) patients; type II (trunk type of right and middle HVs), 54 (21.8%); type III (trunk type of left, middle and right HVs), 14 (5.6%); type IV (non-trunk type of left, middle and right HVs), of which, type IVa, 16 (6.5%), in the same horizontal plane; type IVb, 18 (7.3%), in different horizontal planes; and type V (segment type), 4 (1.6%). The patients whose HVs anatomy belonged to types I, II and III underwent classical piggy-back liver transplantation. Type IVa patients had classical PBLT via HV venoplasty prior to piggy-back anastomosis, while type IVb patients and type V patients could only have modified PBLT. CONCLUSION This study demonstrates that HVs can be classified according to the anatomy of their drainage into the IVC and we can use this classification to choose the best operative approach to PBLT.
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Affiliation(s)
- Ying-Zi Ming
- Research Center of Chinese Health Ministry on Transplantation Medicine Engineering and Technology, The Third Xiangya Hospital, Central South University, Changsha 410013, China.
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20
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Tayar C, Kluger MD, Laurent A, Cherqui D. Optimizing outflow in piggyback liver transplantation without caval occlusion: the three-vein technique. Liver Transpl 2011; 17:88-92. [PMID: 21254349 DOI: 10.1002/lt.22201] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Claude Tayar
- Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Hôpital Henri Mondor, Créteil, France
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21
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Ikeda O, Tamura Y, Nakasone Y, Yamashita Y, Okajima H, Asonuma K, Inomata Y. Percutaneous transluminal venoplasty after venous pressure measurement in patients with hepatic venous outflow obstruction after living donor liver transplantation. Jpn J Radiol 2010; 28:520-6. [PMID: 20799017 DOI: 10.1007/s11604-010-0463-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Accepted: 05/10/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to evaluate retrospectively the outcome of percutaneous transluminal venoplasty (PTV) after venous pressure measurement in patients with hepatic venous outflow obstruction following living donor liver transplantation (LDLT). MATERIALS AND METHODS We studied 24 consecutive patients suspected of having hepatic venous outflow obstruction after LDLT. Pressure gradients were measured proximal and distal to the lesion, and gradient values >3 mmHg were considered hemodynamically significant. We evaluated the technical success, complications, outcome of venoplasty and recurrence, and the patency rate. RESULTS In all, 11 female patients manifested a pressure gradient >3 mmHg across the anastomotic site; they underwent subsequent PVT. The initial balloon venoplasty procedure was technically successful in 10 of the 11 patients (91%), and the pressure gradient was reduced from 5.8 to 1.1 mmHg (P < 0.01). Clinical improvement was observed in 9 of these 10 patients; one patient failed to improve and underwent retransplantation. Recurrent obstruction occurred in four patients; they underwent PTV with (n = 2) or without (n = 2) stent placement. There were no major procedural complications. CONCLUSION PTV following venous pressure measurement is an effective and safe treatment for venous outflow obstruction in patients subjected to LDLT. In patients with recurrent obstruction, re-venoplasty is recommended.
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Affiliation(s)
- Osamu Ikeda
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Medical and Pharmaceutical Sciences, Kumamoto, Japan.
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22
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Audet M, Piardi T, Panaro F, Cag M, Habibeh H, Gheza F, Portolani N, Cinqualbre J, Jaeck D, Wolf P. Four hundred and twenty-three consecutive adults piggy-back liver transplantations with the three suprahepatic veins: was the portal systemic shunt required? J Gastroenterol Hepatol 2010; 25:591-6. [PMID: 19968745 DOI: 10.1111/j.1440-1746.2009.06084.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The aim of this study is to analyze a single-center experience in orthotopic liver transplantation with the piggy-back technique (PB) realized with a cuff of three veins without temporary portacaval shunt. Outcome parameters were graft and patient survival and the surgical complications. METHODS The records of 423 liver transplantation in 396 adult recipients were reviewed. PB was performed in all cases also in patients with transjugular intrahepatic portosystemic shunts and redo transplants without temporary portacaval shunt. No hemodynamic instability was observed during venous reconstruction. RESULTS Operation time, cold ischemia time and anhepatic phase were, respectively, 316, 606 and 82 min, respectively. The mean intraoperative transfusion of packed red blood cells was 3.2 (range 1-48). Surgical complications were observed in 25% of the orthotopic liver transplantation and 2% of these was related to caval anastomosis. No case of caval thrombosis was observed; a stenosis was noted in seven patients, always treated with an endovascular approach. A postoperative ascites was observed in seven cases. Retransplantation was required in 6.3% patients. Overall in-hospital mortality was 5.3%, but no patient died through technical problems or complications related to PB procedure. One-, 3- and 5-year grafts and patients were 94%, 83% and 75%, and 92%, 86% and 79%, respectively. CONCLUSION This experience indicates that our approach is feasible with a low specific risk and can be performed without portacaval shunt, with minimal outflow venous complications.
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Affiliation(s)
- Maxime Audet
- Department of Surgery, Multivisceral Transplant Centre, Hopital Hautepierre, University of Strasbourg, Strasbourg, France
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23
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Hepatic outflow obstruction at middle hepatic vein tributaries or inferior right hepatic veins after living donor liver transplantation with modified right lobe graft: comparison of CT and Doppler ultrasound. AJR Am J Roentgenol 2009; 193:745-51. [PMID: 19696288 DOI: 10.2214/ajr.08.2145] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The objective of our study was to compare CT and Doppler ultrasound in the diagnosis of hepatic outflow obstruction at the middle hepatic vein (MHV) tributaries and inferior right hepatic veins (RHVs) after living donor liver transplantation (LDLT) with modified right lobe grafts. MATERIALS AND METHODS Thirty-seven venographies were performed in 36 patients after LDLT with modified right lobe grafts, evaluating 51 MHV tributaries and 25 inferior RHVs. They were classified as obstructed or nonobstructed. On Doppler ultrasound or CT, flow patterns of the MHV tributaries and inferior RHVs or the relative parenchymal attenuation, enhancement, and opacification of these veins were evaluated for the diagnosis of hepatic outflow obstruction. McNemar tests were performed to compare the diagnostic values of Doppler ultrasound and CT. RESULTS On the basis of hepatic venography, 33 MHV tributaries were categorized as obstructed and 18 as nonobstructed, and 16 inferior RHVs were categorized as obstructed and nine as nonobstructed. For the diagnosis of MHV tributary obstruction, Doppler ultrasound was more sensitive and accurate, although less specific, than CT (97% vs 39%, respectively, p < 0.001; 86% vs 61%, p = 0.0209; 67% vs 100%, p = 0.0412). Similarly, Doppler ultrasound was more sensitive (94% vs 31%, respectively) and accurate (84% vs 56%) than CT, although less specific (67% vs 100%), for the diagnosis of inferior RHV obstruction, with a statistical significance only for sensitivity (p = 0.002, 0.092, and 0.248, respectively). CONCLUSION Doppler ultrasound is more sensitive and accurate than CT for the detection of obstruction at the MHV tributaries and inferior RHVs in patients after LDLT using modified right lobe grafts. Although current CT criteria produce high specificity and may reduce unnecessary invasive venographies, optimal CT criteria with acceptable sensitivity should be reestablished.
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Mehrabi A, Mood ZA, Fonouni H, Kashfi A, Hillebrand N, Müller SA, Encke J, Büchler MW, Schmidt J. A single-center experience of 500 liver transplants using the modified piggyback technique by Belghiti. Liver Transpl 2009; 15:466-74. [PMID: 19399735 DOI: 10.1002/lt.21705] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Over the past 4 decades, the surgical techniques of liver transplantation (LTx) have permanently evolved and been modified. Among these, the modified piggyback (MPB) technique by Belghiti offers specific advantages. The objective of this study was to present our single-center experience with the MPB technique in 500 cases. Recipients' perioperative data were prospectively collected and evaluated. Postoperative and specific complications, stay in the intensive and intermediate care unit, and the mortality rate with cause of death were analyzed. Most recipients were classified as Child C (49.1%). For the patients who underwent LTx for the first time, alcoholic (23.9%) and viral (22.2%) cirrhosis and hepatocellular carcinoma (15.1%) were the prevalent indications. The overall median warm ischemia time, anastomosis duration, and operative time were 45, 108, and 320 minutes, respectively. The median intraoperative blood loss was 1500 mL. A venovenous bypass was never needed to maintain hemodynamic stability. Only in a few cases was temporary inferior vena cava clamping necessary. Most prominent surgical complications were hemorrhage, hematoma, and wound dehiscence. Renal failure occurred in 6.2% of patients. The overall median stay in the intensive and intermediate care unit was 14 days. The mortality rates within 30 and 90 days were 6.3% and 13.3%, respectively. No technique-related death occurred. The MPB technique by Belghiti is a feasible and simple LTx technique. The caval flow is preserved during the anhepatic phase, and this minimizes the need for venovenous bypass or portocaval shunt. This technique requires only 1 caval anastomosis, which is easy to perform with a short anhepatic phase. To minimize the risk of outflow obstruction, attention should be paid by doing a wide cavocavostomy cranially to the donor inferior vena cava in a door-lock manner. This technique can be applied in almost all patients undergoing LTx for the first time and liver retransplantation as well.
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Affiliation(s)
- Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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Dondéro F, Liddo G, Andraus W, Sommacale D, Sauvanet A, Belghiti J. Left-to-right approach facilitates total hepatectomy with caval flow preservation. Liver Transpl 2008; 14:1380-2. [PMID: 18756489 DOI: 10.1002/lt.21503] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Federica Dondéro
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hospital Beaujon, Clichy, France
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26
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Fonouni* H, Mehrabi * A, Soleimani M, Müller SA, Büchler MW, Schmidt J. The need for venovenous bypass in liver transplantation. HPB (Oxford) 2008; 10:196-203. [PMID: 18773054 PMCID: PMC2504375 DOI: 10.1080/13651820801953031] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Indexed: 12/12/2022]
Abstract
Since introduction of the conventional liver transplantation (CLTx) by Starzl, which was based on the resection of recipient inferior vena cava (IVC) along the liver, the procedure has undergone several refinements. Successful use of venovenous bypass (VVB) was first introduced by Shaw et al., although in recent decades there has been controversy regarding the routine use of VVB during CLTx. With development of piggyback liver transplantation (PLTx), the use of caval clamping and VVB is avoided, leading to fewer complications related to VVB. However, some authors still advocate VVB in PLTx. The great diversity among centers in their use of VVB during CLTx, or even along the PLTx technique, has led to confusion regarding the indication setting for VVB. For this reason, we present an overview of the use of VVB in CLTx, the target of patients for whom VVB could be beneficial, and the needs assessment of VVB for patients undergoing PLTx. Recent studies have shown that with the advancement of surgical skills, refinement of surgical techniques, and improvements in anesthesiology, there are only limited indications for doing CLTx with VVB routinely. PLTx with preservation of IVC can be performed in almost all primary transplants and in the majority of re-transplantations without the need for VVB. Nevertheless, in a few selective cases with severe intra-operative hemodynamic instability, or with a failed test of transient IVC occlusion, the application of VVB is still justifiable. These indications should be judged intra-operatively and the decision is based on each center's preference.
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Affiliation(s)
- Hamidreza Fonouni*
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
| | - Arianeb Mehrabi*
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
| | - Mehrdad Soleimani
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
| | - Sascha A. Müller
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
| | - Markus W. Büchler
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
| | - Jan Schmidt
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
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Doppler sonography to diagnose venous congestion in a modified right lobe graft after living donor liver transplantation. AJR Am J Roentgenol 2008; 190:1010-7. [PMID: 18356449 DOI: 10.2214/ajr.07.2825] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective of our study was to assess the value of Doppler sonography for the diagnosis of hepatic venous congestion in a modified right lobe graft during the early postoperative period after living donor liver transplantation. SUBJECTS AND METHODS Doppler sonography examinations were prospectively performed in 54 patients within 24 hours after living donor liver transplantation with a modified right lobe graft in which large (> 5 mm) middle hepatic vein (MHV) tributaries were reconstructed. The number, flow direction, and waveform of the MHV tributaries; the echogenicity of the surrounding parenchyma; and the flow direction of the corresponding portal branch were evaluated. Hepatic venous congestion was diagnosed when there was no color flow or a monophasic waveform of an MHV tributary. The sensitivity of Doppler sonography for the detection of MHV tributaries was assessed using donors' preoperative CT scans and surgical records as references. The diagnostic values of Doppler sonography for hepatic venous congestion were assessed using recipients' postoperative CT scans as references. Differences in prevalence of Doppler sonography findings between the group with hepatic venous congestion and the non-hepatic venous congestion group were assessed. RESULTS Doppler sonography enabled us to identify 90% (155/173) of all and 98% (129/131) of the large MHV tributaries. The sensitivity and specificity of Doppler sonography for hepatic venous congestion were 90% (28/31) and 77% (96/124), respectively, for all and 88% (15/17) and 85% (95/112), respectively, for large MHV tributaries. Parenchymal hyperechogenicity was more commonly seen in the hepatic venous congestion group (65%, 20/31) than in non-hepatic venous congestion group (6%, 7/124) (p < 0.01). All five MHV tributaries with reversed flow were seen in the non-hepatic venous congestion group. All five portal branches with hepatofugal flow were seen in the hepatic venous congestion group. CONCLUSION Doppler sonography provides a reliable noninvasive surveillance tool for hepatic venous congestion in a modified right lobe graft during the early postoperative period after living donor liver transplantation.
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Lee SS, Kim KW, Park SH, Shin YM, Kim PN, Lee SG, Lee MG. Value of CT and Doppler Sonography in the Evaluation of Hepatic Vein Stenosis After Dual-Graft Living Donor Liver Transplantation. AJR Am J Roentgenol 2007; 189:101-8. [PMID: 17579158 DOI: 10.2214/ajr.06.1366] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the imaging findings and role of CT and Doppler sonography in the diagnosis of hepatic vein (HV) stenosis after dual-graft living donor liver transplantation (LDLT). MATERIALS AND METHODS Using hepatic venography as the reference standard, 73 grafts with venographic evaluation in 43 dual-graft LDLT recipients were classified into either a stenosis (n = 39) or a nonstenosis (n = 34) group. CT scans were evaluated for relative attenuation, enhancement pattern, and HV abnormality for each graft. Doppler sonography evaluation of the flow pattern of HVs for each graft was performed. CT and Doppler sonography findings were compared in the stenosis and nonstenosis groups using the independent sample Student's t test and Fisher's exact test. Multifactorial logistic regression analysis was performed to determine the best predictors of the diagnosis of HV stenosis. RESULTS Heterogeneous enhancement (p = 0.046), abnormal HV on CT (p = 0.025), and HV wave pattern on Doppler sonography (p = 0.005) were significant findings. The accuracy for the diagnosis of HV stenosis was 60.0% for heterogeneous enhancement, 61.5% for abnormal HV, and 66.2% for a monophasic flow pattern. Heterogeneous enhancement and HV wave pattern were significant independent findings on multifactorial logistic regression analysis. The overall accuracy of the logistic model in the diagnosis of HV stenosis was 71.7%. CONCLUSION Although CT and Doppler sonography can be helpful in diagnosing HV stenosis, given the low accuracy of individual imaging findings, the diagnosis of HV stenosis should be made cautiously, with both CT and Doppler sonography regarded as complementary examinations.
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Affiliation(s)
- Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1, Pungnap-2 dong, Songpa-ku, Seoul 138-736, Korea
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Miraglia R, Luca A, Marrone G, Caruso S, Cintorino D, Spada M, Gridelli B. Percutaneous transhepatic venous angioplasty in a two-yr-old patient with hepatic vein stenosis after partial liver transplantation. Pediatr Transplant 2007; 11:222-4. [PMID: 17300506 DOI: 10.1111/j.1399-3046.2006.00625.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
We report one case of severe hepatic vein stenosis, in a two-yr-old pediatric patient with a left lateral split liver transplantation (S2-S3) and severe ascites, in whom color Doppler ultrasound failed to make the diagnosis and transhepatic balloon angioplasty was successfully performed.
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Affiliation(s)
- Roberto Miraglia
- Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IsMeTT), Palermo, Italy, University of Pittsburgh Medical Center, Italy.
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Polak WG, Nemes BA, Miyamoto S, Peeters PMJG, de Jong KP, Porte RJ, Slooff MJH. End-to-side caval anastomosis in adult piggyback liver transplantation. Clin Transplant 2007; 20:609-16. [PMID: 16968487 DOI: 10.1111/j.1399-0012.2006.00525.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
No consensus exists regarding the optimal reconstruction of the cavo-caval anastomosis in piggyback orthotopic liver transplantation (PB-LT). The aim of this study was to analyze our experience with end-to-side (ES) cavo-cavostomy. Outcome parameters were patient and graft survival and surgical complications. During the period 1995-2002 146 full-size PB-LT in 137 adult patients were performed with ES cavo-cavostomy without the routine use of temporary portocaval shunt (TPCS). In 12 patients (8%) this technique was used for implantation of second or third grafts. Veno-venous bypass was not used in any case and TPCS was performed only in eight patients (6%). One-, three- and five-yr patient and graft survival were 84%, 79% and 75%, and 81%, 74% and 69%, respectively. The median number of intraoperative transfusion of packed red blood cells (RBC) was 2.0 (range 0-33) and 30% of the patients (n = 43) did not require any RBC transfusion. Surgical complications of various types were observed after 49 LT (34%) and none of the complications was specifically related to the technique of ES cavo-cavostomy. Our experience indicates that PB-LT with ES cavo-cavostomy is a safe procedure, can safely be performed without the routine use of a TPCS, has a very low risk of venous outflow obstruction and can also be used effectively during retransplantations.
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Affiliation(s)
- Wojciech G Polak
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Cheaito A, Craig B, Abouljoud M, Arenas J, Yoshida A, Malinzak L, Almarastani M, Kim DY. Sonographic differences in venous return between piggyback versus caval interposition in adult liver transplantations. Transplant Proc 2006; 38:3588-90. [PMID: 17175339 DOI: 10.1016/j.transproceed.2006.10.128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Indexed: 11/20/2022]
Abstract
UNLABELLED The piggyback technique (PT) is being used more frequently than caval interposition (CI) in adult orthotopic liver transplants (OLT). It is unclear whether PT alters venous return compared with CI, therefore leading to postoperative complications. The aim of our study was to analyze our experience with PT and CI by comparing ultrasound results of hepatic vein flow on the first postoperative day. PATIENTS AND METHODS This retrospective analysis of consecutive OLTs performed between 2002 and 2005 included data from a single blinded radiologist who reviewed all postoperative day 1 ultrasound examinations. The hepatic vein waveforms were scored as all phasic, all flat, or partially phasic/flat. RESULTS During the study period, we performed, 465 OLT among which 270 had available ultrasound examinations. The etiologies of liver disease were similar between the PT and CI cohorts, hepatitis C and alcoholic liver disease accounted for more than 60%. Two hundred eight (77%) had undergone PT and 62 (23%) CI. Among the PT, 60% were phasic, 31.1% were partially phasic/flat, and 8% were flat. When a CI was performed, 56.5% were phasic, 35.5% were partially phasic/flat, and 8% were flat. CONCLUSIONS There was no significant difference between PT and CI with regard to an effect on hepatic vein waveforms on the first operative day. Therefore, there do not appear to be early hemodynamic benefits of performing CI versus PT anastamoses of OLTs. Further studies may be needed to determine whether long-term sequelae follow the piggyback technique.
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Affiliation(s)
- A Cheaito
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan 48202, USA
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Kubo T, Shibata T, Itoh K, Maetani Y, Isoda H, Hiraoka M, Egawa H, Tanaka K, Togashi K. Outcome of percutaneous transhepatic venoplasty for hepatic venous outflow obstruction after living donor liver transplantation. Radiology 2006; 239:285-90. [PMID: 16567488 DOI: 10.1148/radiol.2391050387] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate retrospectively the outcome of percutaneous transhepatic venoplasty of hepatic venous outflow obstruction after living donor liver transplantation (LDLT). MATERIALS AND METHODS The institutional Human Subjects Research Review Board approved the interventional protocol and the retrospective study, for which informed consent was not required. Before treatment, informed consent was obtained from the patient or the patient's parents in all cases. Of 26 consecutive patients (nine male, 17 female; median age, 9 years) suspected of having hepatic venous outflow obstruction after LDLT, 20 patients confirmed to have anastomotic outflow stenosis at percutaneous hepatic venography and manometry underwent venoplasty. Pressure gradients before and after venoplasty were evaluated by using a paired t test. Patients in whom obstruction recurred during follow-up were re-treated with venoplasty with or without expandable metallic stents. Patency was analyzed by using Kaplan-Meier analysis. RESULTS The initial balloon venoplasty was technically successful in all 20 patients, all of whom had improved clinical findings. The pressure gradient +/- standard deviation was reduced from 14.6 mg Hg +/- 8.6 to 2.2 mg Hg +/- 2.4 (P < .001). Eleven patients had recurrent obstruction and were treated with balloon venoplasty; one of them underwent stent placement, as well as venoplasty. The primary (event-free) patency and 95% confidence interval (CI) at 3, 12, and 60 months after venoplasty were 0.80 (95% CI: 0.62, 0.98), 0.60 (95% CI: 0.38, 0.81), and 0.60 (95% CI: 0.38, 0.81), respectively. The primary assisted patency, maintained with repeated venoplasty and expandable metallic stents, was 1.00 at 60 months. CONCLUSION Percutaneous venoplasty is an effective treatment for hepatic venous outflow obstruction after LDLT.
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Affiliation(s)
- Takeshi Kubo
- Department of Radiology, Kyoto University Graduate School of Medicine, 54-Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan
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Nishida S, Nakamura N, Vaidya A, Levi DM, Kato T, Nery JR, Madariaga JR, Molina E, Ruiz P, Gyamfi A, Tzakis AG. Piggyback technique in adult orthotopic liver transplantation: an analysis of 1067 liver transplants at a single center. HPB (Oxford) 2006; 8:182-8. [PMID: 18333273 PMCID: PMC2131682 DOI: 10.1080/13651820500542135] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) in adult patients has traditionally been performed using conventional caval reconstruction technique (CV) with veno-venous bypass. Recently, the piggyback technique (PB) without veno-venous bypass has begun to be widely used. The aim of this study was to assess the effect of routine use of PB on OLTs in adult patients. PATIENTS AND METHODS A retrospective analysis was undertaken of 1067 orthotopic cadaveric whole liver transplantations in adult patients treated between June 1994 and July 2001. PB was used as the routine procedure. Patient demographics, factors including cold ischemia time (CIT), warm ischemia time (WIT), operative time, transfusions, blood loss, and postoperative results were assessed. The effects of clinical factors on graft survival were assessed by univariate and multivariate analyses.In all, 918 transplantations (86%) were performed with PB. Blood transfusion, WIT, and usage of veno-venous bypass were less with PB. Seventy-five (8.3%) cases with PB had refractory ascites following OLT (p=NS). Five venous outflow stenosis cases (0.54%) with PB were noted (p=NS). The liver and renal function during the postoperative periods was similar. Overall 1-, 3-, and 5-year patient survival rates were 85%, 78%, and 72% with PB. Univariate analysis showed that cava reconstruction method, CIT, WIT, amount of transfusion, length of hospital stay, donor age, and tumor presence were significant factors influencing graft survival. Multivariate analysis further reinforced the fact that CIT, donor age, amount of transfusion, and hospital stay were prognostic factors for graft survival. CONCLUSIONS PB can be performed safely in the majority of adult OLTs. Results of OLT with PB are as same as for CV. Liver function, renal function, morbidity, mortality, and patient and graft survival are similar to CV. However, amount of transfusion, WIT, and use of veno-venous bypass are less with PB.
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Affiliation(s)
- Seigo Nishida
- Division of Transplantation, Department of Surgery, University of Miami/Jackson Memorial Medical Center, Miami, FL, USA.
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Guimarães M, Uflacker R, Schönholz C, Hannegan C, Selby JB. Stent Migration Complicating Treatment of Inferior Vena Cava Stenosis after Orthotopic Liver Transplantation. J Vasc Interv Radiol 2005; 16:1247-52. [PMID: 16151067 DOI: 10.1097/01.rvi.0000167586.44204.c8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A case of inferior vena cava (IVC) stenosis after orthotopic liver transplantation was treated with balloon angioplasty and Wallstent placement. There was stent migration into the right atrium (RA), and percutaneous removal of the stent was attempted without success. Open cardiac surgery was required for stent removal and repair of aortic/RA fistula. Months later, recurrent IVC stenosis was successfully treated with placement of large Z stents after additional failed surgical repair. At 2 years follow-up, the patient is asymptomatic and Doppler ultrasonography demonstrated the stent to be patent and well-positioned.
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Affiliation(s)
- Marcelo Guimarães
- Division of Interventional Radiology, Department of Radiology, Medical University of South Carolina, 169 Ashley Ave., Box 250322, Charleston, South Carolina 29425, USA.
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Cescon M, Grazi GL, Varotti G, Ravaioli M, Ercolani G, Gardini A, Cavallari A. Venous outflow reconstructions with the piggyback technique in liver transplantation: a single-center experience of 431 cases. Transpl Int 2005; 18:318-25. [PMID: 15730493 DOI: 10.1111/j.1432-2277.2004.00057.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The ideal method of venous outflow reconstruction with the piggyback technique (PB) in orthotopic liver transplantation (OLT) is not well-established. The complications related to PB in 431 primary OLTs were analyzed comparing the orifices used for the anastomosis (cuff of the recipient left and middle hepatic veins [LM], LM with a >1 cm cavoplasty [LM+], or also including the right hepatic vein [LMR]). Treatment strategies and outcome were also evaluated. Twenty patients (4.6%) experienced complications: 13 of 120 (10.8%) with LM, four of 225 (1.8%) with LM+, and three of 86 (3.5%) with LMR (LM versus LM+: P < 0.0001; LM versus LMR: P = NS; LM+ versus LMR = NS). Balloon dilation was successful in 10 of 13 cases in which it was attempted (77%). Eight patients required retransplantation (40%). Three patients (0.7%) died from causes linked to stenosis. Five-year survival of patients with and without complications was 75% and 79%, respectively (P =NS); 5-year graft survival was 50% and 76%, respectively (P = 0.001). The stump formed by the recipient left and middle hepatic veins with a transversal incision >1 cm of the caval wall constantly provides an adequate width for the caval anastomosis with the PB.
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Affiliation(s)
- Matteo Cescon
- Department of Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
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Wang SL, Sze DY, Busque S, Razavi MK, Kee ST, Frisoli JK, Dake MD. Treatment of hepatic venous outflow obstruction after piggyback liver transplantation. Radiology 2005; 236:352-9. [PMID: 15955856 DOI: 10.1148/radiol.2361040327] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE To evaluate retrospectively the endovascular management of hepatic venous outflow obstruction after piggyback orthotopic liver transplantation. MATERIALS AND METHODS The study was performed with the approval and under the guidelines of the institutional review board and complied with the Health Insurance Portability and Accountability Act. Informed consent from patients was not required by the institutional review board for this retrospective study. From 1995 to 2003, 13 patients (eight male, five female), including 12 adults and one adolescent (age range, 14-67 years; median age, 52 years), underwent endovascular treatment of hepatic venous outflow obstruction after piggyback orthotopic liver transplantation. Patients gave informed consent for all procedures. Eleven patients received whole livers, and two received living-related donor right liver lobes. Four underwent repeat piggyback orthotopic liver transplantation prior to intervention. Primary stent placement was performed in 12 patients. One patient refused primary stent placement and chose venoplasty alone, but required a stent 5 months later. Short balloon-expandable stents (mean diameter, 14.6 mm +/- 1.1 [standard deviation]) were used to minimize jailing of branch vessels and to resist recoil. Pre- and post-procedural pressure gradients were measured. Follow-up included venography, cross-sectional imaging, and laboratory tests. The Wilcoxon signed rank test or the sign test was performed to compare pre- and post-procedural pressure gradients, body weights, and laboratory values. RESULTS Technical success (pressure gradient < or = 3 mm Hg) was achieved in 13 of 13 patients, and clinical success, in 12 of 13. Mean pre- and post-procedural pressure gradients were 13.0 mm Hg +/- 1.4 and 0.8 mm Hg +/- 0.3. Mean interval from transplantation to intervention was 348 days +/- 159. Mean follow-up was 678 days (range, 16-2880 days). Technical success did not result in clinical improvement in one patient. Biopsy demonstrated severe hepatic necrosis, likely from prolonged venous congestion, and the patient required repeat transplantation. Only one patient required reintervention for stent migration, and no other complications occurred. No significant restenosis was encountered after stent placement. CONCLUSION Hepatic venous outflow obstruction is an uncommon but potentially fatal complication of piggyback orthotopic liver transplantation. Endovascular treatment with balloon-expandable stents is effective, safe, and apparently durable.
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Affiliation(s)
- Stephen L Wang
- Division of Vascular and Interventional Radiology, Stanford University Medical Center, H3646, 300 Pasteur Dr, Stanford, CA 94305-5642, USA
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Lerut J, Ciccarelli O, Roggen F, Laterre PF, Danse E, Goffette P, Aunac S, Carlier M, De Kock M, Van Obbergh L, Veyckemans F, Guerrieri C, Reding R, Otte JB. Cavocaval adult liver transplantation and retransplantation without venovenous bypass and without portocaval shunting: a prospective feasibility study in adult liver transplantation. Transplantation 2003; 75:1740-5. [PMID: 12777866 DOI: 10.1097/01.tp.0000061613.66081.09] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The original method of liver transplantation (LT) included recipient inferior vena cava (IVC) resection and the use of extracorporeal venovenous bypass (VVB). Refinements in technique permit transplantation to be done with IVC preservation and without VVB use. MATERIAL AND METHODS Between November 1993 and November 2000, 202 consecutive grafts were performed in 188 adults (>/=16 years of age). Twelve patients (6.4%) received two and three retransplants (re-LT). Split grafting was performed 19 times (19 of 202 grafts, 9.4%). Risk factors included United Network of Organ Sharing status I (n=30, 16%), previous right upper abdominal surgery (n=32, 17.1%), caudate lobe encirclement of IVC (n=65, 32.2%), IVC (n=24, 11.9%), and splanchnic venous modification (n=58, 30.9%), transjugular intrahepatic portosystemic stent shunt (n=34, 16.8%), giant (>5 kg) liver tumor (n=6, 3%), septic necrosis of the caudate lobe (n=1, 0.5%), and previous cavocaval (n=13, 6.4%) or classical LT (n=5, 2.5%). RESULTS IVC preservation, avoidance of IVC cross clamping and of VVB use were possible in 98.9%, 93%, and 99.5% of 183 primary LT and in 89.5%, 84.2%, and 89.5% of 19 re-LT. Temporary portocaval shunting was never applied. Perioperative mortality was 1.2%. There was no allotransfusion in 73 (36%) grafts and 45 (22%) patients were immediately extubated. Permanent hepatic vein and caval problems were encountered in three (1.5%) grafts. One patient needed stent placement to treat IVC stenosis. Actual 3- and 12-month patient survival for whole, re-LT, and right-lobe split LT groups were 94.7%, 94.1%, 94.7%, 88.2%, 94.1%, and 89%. Three-month graft survival rates for these groups were 92.6%, 94.7%, and 84.2%. CONCLUSIONS LT with IVC preservation and without VVB use and portocaval shunting is possible in nearly all primary transplants and in the majority of re-LT.
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Affiliation(s)
- Jan Lerut
- Department of Digestive Surgery, Liver Transplant Program, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.
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Leonardi LS, Boin IFSF, Leonardi MI, Tercioti V. Ascites after liver transplantation and inferior vena cava reconstruction in the piggyback technique. Transplant Proc 2002; 34:3336-8. [PMID: 12493466 DOI: 10.1016/s0041-1345(02)03575-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- L S Leonardi
- Unit of Liver Transplantation, Department of Surgery, University of Campinas Medical School, São Paulo, Brazil
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Ko GY, Sung KB, Yoon HK, Kim JH, Song HY, Seo TS, Lee SG. Endovascular treatment of hepatic venous outflow obstruction after living-donor liver transplantation. J Vasc Interv Radiol 2002; 13:591-9. [PMID: 12050299 DOI: 10.1016/s1051-0443(07)61652-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To evaluate the effectiveness and safety of percutaneous interventional management of hepatic venous outflow obstruction after living-donor liver transplantation (LDLT). MATERIALS AND METHODS Percutaneous balloon angioplasty (n = 5) and stent placement (n = 22) were attempted in 27 patients with hepatic venous outflow obstruction. Patient follow-up included clinical and laboratory data collection, Doppler ultrasonography (US), hepatic venography, and computed tomography. The following parameters were documented retrospectively: technical success and complications, clinical improvement, and recurrence. Technical success was defined as elimination or successful reduction of pressure gradients across the stenosis and clinical success was defined as amelioration of presenting signs. Recurrence was defined as relapse of clinical signs with hepatic venous anastomotic restenosis on Doppler US. RESULTS Technical success was achieved in all patients. The mean pressure gradients across the stenoses before and after the procedure were 10.6 mm Hg +/- 6.4 (range, 3-39 mm Hg) and 2.4 mm Hg +/- 2.6 (range, 0-8 mm Hg), respectively (P < .001). Three of the five patients who underwent balloon angioplasty developed recurrent stenosis 1-5 weeks after the procedure. These patients underwent repeat balloon angioplasty, and two of them eventually underwent stent placement (n = 1) or surgical repositioning (n = 1) of the graft. Three of the 22 patients who underwent stent placement required a second stent placement procedure because of malpositioning, partial migration, and acute angulation. During the mean follow-up period of 49 weeks +/- 47 (range, 3-214 wk), clinical success was achieved in 20 of 27 patients (73%). CONCLUSION Percutaneous interventional management is an effective and safe adjunct for the treatment of hepatic venous outflow obstruction after LDLT.
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Affiliation(s)
- Gi-Young Ko
- Departments of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap-Dong, Songpa-Ku, Seoul 138-736, Korea
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Wu YM, Voigt M, Rayhill S, Katz D, Chenhsu RY, Schmidt W, Miller R, Mitros F, Labrecque D. Suprahepatic venacavaplasty (cavaplasty) with retrohepatic cava extension in liver transplantation: experience with first 115 cases. Transplantation 2001; 72:1389-94. [PMID: 11685109 DOI: 10.1097/00007890-200110270-00010] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND We first introduced the orthotopic liver transplantation utilizing cavaplasty technique in 1994. This paper describes the surgical technique and assesses the outcome of the cavaplasty OLT. METHODS The cavaplasty procedure was used in 115 consecutive orthotopic liver transplantations, including six left lateral and two right lobe transplantations, between November 1994 and September 2000. Fifty-three (66.3%) transplantations required femoro-axillary veno-venous bypass in the initial 4 years, whereas only eight (22.9%) needed VB in the subsequent 2 years. Conversion to piggyback or standard technique was not necessary in any patient. RESULTS Median results are as follows: operative time 4.5 hr, warm ischemia time 25 min, and blood transfused (packed red blood cells) 6 units. These findings did not differ between first transplantation and retransplantation. There were no perioperative deaths related to the cavaplasty technique. No hepatic venous outflow obstruction was observed, including living-related OLTs. No patient required postoperative hemodialysis for acute renal failure. The median intensive care and hospital stays were 2 days and 10 days, respectively. CONCLUSIONS The cavaplasty technique requires no retrocaval, hepatic vein, or short hepatic vein dissection, and the inferior vena cava can be preserved, which provides advantages for hepatectomy and easy hemostasis, especially during retransplantation. The wide-open triangular caval anastomosis is easy to perform, allowing short implantation time and size matching and avoiding outflow obstruction. The short implantation time reduces the need for veno-venous bypass. Our experience indicates that the cavaplasty technique can be applied to all patients and is justified by minimal technical complications.
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Affiliation(s)
- Y M Wu
- Department of Surgery, University of Iowa, 200 Hawkins Dr., Iowa City, IA 52242, USA.
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Mor E, Pappo O, Bar-Nathan N, Shaharabani E, Shapira Z, Tur-Kaspa R, Ben-Ari Z. Defibrotide for the treatment of veno-occlusive disease after liver transplantation. Transplantation 2001; 72:1237-40. [PMID: 11602848 DOI: 10.1097/00007890-200110150-00009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Veno-occlusive disease (VOD) after liver transplantation is associated with acute rejection and poor outcome. The use of antithrombotic and thrombolytic agents is limited by their toxicity. Defibrotide is a polydeoxyribonucleotide with thrombolytic and antithrombotic properties and no systemic anticoagulant effect. METHODS Defibrotide, 35-40 mg/kg/day, was administered intravenously for 21 days on a compassionate-use basis to two patients aged 66 and 49 years. VOD had developed 6 weeks and 4 months after orthotopic liver transplantation for hepatitis C and hepatitis B infection, respectively. VOD was diagnosed clinically by findings of weight gain (8.5% and 16%), ascites, jaundice (serum bilirubin 5.4 mg/dl and 21.7 mg/dl), and severe coagulopathy (in one patient), and histologically by the presence of hemorrhagic centrilobular necrosis and fibrous stenosis of the hepatic venules. One of the patients had received azathioprine as part of the immunosuppressive regimen. There was no evidence of acute cellular rejection histologically. RESULTS After 3 weeks of defibrotide administration, the first patient showed complete clinical resolution of the VOD, and serum bilirubin level normalized. He is alive 6 months after transplantation. The second patient, treated at a later stage of disease, showed marked improvement in the coagulopathic state, but there was no resolution of the VOD. He died 2 months later of multiorgan failure due to Escherichia coli sepsis. Neither patient had side effects from the drug. CONCLUSIONS Defibrotide is a promising drug for the treatment of VOD after liver transplantation and needs to be evaluated in large, prospective studies.
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Affiliation(s)
- E Mor
- Department of Transplantation, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49 100, Israel
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Keegan MT, Kamath GS, Vasdev GM, Findlay JY, Gores GJ, Steers JL, Plevak DJ. Liver transplantation for massive hepatic haemangiomatosis causing restrictive lung disease. Br J Anaesth 2001; 86:431-4. [PMID: 11573537 DOI: 10.1093/bja/86.3.431] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A 34-yr-old man with hepatic haemangiomatosis presented for orthotopic liver transplantation. His massively distended abdomen caused thoracic compression and severe restrictive lung disease. Respiratory failure was the principal indication for transplantation. Increased airway pressures, pulmonary hypertension, systemic hypotension caused by aorto-caval compression, and blood loss, complicated the intra-operative anaesthetic management. Weaning from mechanical ventilation was impaired by acute and chronic metabolic alkalosis, and diaphragmatic laxity.
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Affiliation(s)
- M T Keegan
- Department of Anesthesiology and Critical Care, Mayo Clinic, Rochester, MN 55905, USA
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Gerber DA, Passannante A, Zacks S, Johnson MW, Shrestha R, Fried M, Fair JH. Modified piggyback technique for adult orthotopic liver transplantation. J Am Coll Surg 2000; 191:585-9. [PMID: 11085741 DOI: 10.1016/s1072-7515(00)00702-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D A Gerber
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill 27599, USA
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Ducerf C, Mechet I, Landry JL, DeLaRoche E, Berthoux N, Bourdeix O, Adham M, Bizollon T, Baulieux J. Hemodynamic profiles during piggyback liver grafts using arterial or portal revascularization. J Am Coll Surg 2000; 190:89-93. [PMID: 10625238 DOI: 10.1016/s1072-7515(99)00227-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The order of revascularization in human liver grafts is still discussed. This study tries to answer this question in terms of hemodynamic data. STUDY DESIGN Fifty-nine patients were randomized in this study to compare hemodynamic data just before and 15 minutes after revascularization of liver grafts in relation to first hepatic artery (n = 29) or first portal vein (n = 30) revascularization procedure. RESULTS Hemodynamic variations were significantly greater in the portal vein group than in the hepatic artery group in terms of mean arterial pressure, cardiac index, central venous pressure, pulmonary capillary pressure, and systemic vascular resistance. The latter decreased from 741.8 +/- 390.3 to 659.9 +/- 411.1 dynes/ cm5 (NS) in the hepatic artery group versus 807.7 +/-336.7 to 439.7 +/- 215 dynes/cm5 (p < 0.05) in the portal vein group. Clinical results and postoperative complications, graft characteristics, patient survival, and graft survival were not significantly different between the groups. CONCLUSIONS Initial arterial revascularization of the liver graft leads to a more stable hemodynamic profile during revascularization of the liver graft after vascular unclamping. This technique is always feasible and has become our reference procedure.
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Affiliation(s)
- C Ducerf
- Department of Digestive Surgery and Transplantation, Croix-Rousse Hospital, Lyon, France
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Parrilla P, Sánchez-Bueno F, Figueras J, Jaurrieta E, Mir J, Margarit C, Lázaro J, Herrera L, Gomez-Fleitas M, Varo E, Vicente E, Robles R, Ramirez P. Analysis of the complications of the piggy-back technique in 1112 liver transplants. Transplant Proc 1999; 31:2388-9. [PMID: 10500633 DOI: 10.1016/s0041-1345(99)00394-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- P Parrilla
- Hospital Universitario, V Arrixaca, Murcia, Spain
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Robles R, Parrilla P, Acosta F, Bueno FS, Ramirez P, Lopez J, Lujan JA, Rodriguez JM, Fernandez JA, Picó F. Complications related to hepatic venous outflow in piggy-back liver transplantation: two- versus three-suprahepatic-vein anastomosis. Transplant Proc 1999; 31:2390-1. [PMID: 10500634 DOI: 10.1016/s0041-1345(99)00395-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- R Robles
- Department of Surgery, V Arrixaca University Hospital, Murcia, Spain
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47
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Sze DY, Semba CP, Razavi MK, Kee ST, Dake MD. Endovascular treatment of hepatic venous outflow obstruction after piggyback technique liver transplantation. Transplantation 1999; 68:446-9. [PMID: 10459550 DOI: 10.1097/00007890-199908150-00018] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The piggyback technique of orthotopic liver transplantation is an attractive alternative that preserves the recipient inferior vena cava and allows uninterrupted venous blood return during the anhepatic phase. As with other transplantation techniques, the vascular anastomoses required by the piggyback technique can develop strictures. METHODS Review of records of 264 piggyback transplantations revealed two cases of delayed-onset hepatic venous obstruction from anastomotic strictures. Both patients also had symptoms of inferior vena cava obstruction, with azotemia and lower extremity edema. Both patients were treated percutaneously with balloon-expandable stents. RESULTS Rapid, dramatic resolution of symptoms was achieved in both patients. Patients remain completely asymptomatic at 39 and 3 months of follow-up. CONCLUSIONS Hepatic venous anastomotic strictures in recipients of piggyback technique transplants are a very uncommon complication. They may be easily and effectively treated by minimally invasive endovascular intervention.
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Affiliation(s)
- D Y Sze
- Division of Cardiovascular and Interventional Radiology, Stanford University Medical Center, California 94305-1056, USA
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48
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Parrilla P, Sánchez-Bueno F, Figueras J, Jaurrieta E, Mir J, Margarit C, Lázaro J, Herrera L, Gómez-Fleitas M, Varo E, Vicente E, Robles R, Ramirez P. Analysis of the complications of the piggy-back technique in 1,112 liver transplants. Transplantation 1999; 67:1214-7. [PMID: 10342311 DOI: 10.1097/00007890-199905150-00003] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The "piggy-back" technique has gained acceptance in adult orthotopic liver transplantation during the last few years, especially in European countries. At the moment, however, there is controversy over advantages or specific complications (suprahepatic thrombosis or narrowing, etc.) related to this surgical technique. The aim of this study is to know of the immediate per-and postoperative morbidity and mortality rates in 1112 orthotopic liver transplantations performed with a vena cava preservation technique. METHODS All liver transplant units in Spain were sent a questionnaire on retrohepatic vena cava preservation during orthotopic liver transplantation. The number of orthotopic liver transplantations that had been performed in the seven centers that answered the questionnaire, because the beginning of the program, was 1674, with the vena cava preservation technique used in 1112. RESULTS Twenty-eight patients (2.5%) had intraoperative complications related to the vena cava preservation technique, which were treated during the operation. Eleven patients (1%) had early postoperative complications (first week), the most frequent (nine cases) being an acute Budd-Chiari syndrome in the first 48 hr. Three patients developed symptoms of massive ascites between 2 and 3 months (late postoperative complications), with patency of the retrohepatic cava verified by cavography. A hemodynamic study revealed a hyperpressure at the suprahepatic veins. This chronic Budd-Chiari syndrome was controlled in all patients with diuretics. Only six patients (0.5%) died as a result of complications related to the "piggy-back" technique. These complications were more frequent when venous reconstruction was done using two suprahepatic veins than when the three veins were used (P<0.001). CONCLUSIONS The vena cava preservation technique can be used routinely in orthotopic liver transplantation because it is safe and efficient and involves few surgical complications especially if for venous reconstruction we use the patch obtained by joining the three suprahepatic veins.
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Affiliation(s)
- P Parrilla
- Hospital Universitario Virgen de la Arrixaca (Murcia), Spain
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Rode A, Ducerf C, Adham M, Delaroche E, Berthoux N, Bizollon T, Baulieux J. Influence of systematic echodoppler arterial survey on hepatic artery thrombosis after liver transplantation in adults. Transpl Int 1998. [DOI: 10.1111/j.1432-2277.1998.tb01137.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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