Sutureless portal vein reconstruction in porcine orthotopic liver transplantation using a microvascular coupler: A randomized study with artificial intelligence-assisted histopathology

doi:10.4240/wjgs.120360

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World Journal of Gastrointestinal Surgery

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1948-9366

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastrointest Surg. Aug 27, 2026; 18(8): 120360
Published online Aug 27, 2026. doi: 10.4240/wjgs.120360

Sutureless portal vein reconstruction in porcine orthotopic liver transplantation using a microvascular coupler: A randomized study with artificial intelligence-assisted histopathology

Jun-Jie Li, Jian Yang, Yan Xie, Jia-Ming Shang, Jiang Li, Chi-Yi Chen, Li-Na Liu, Zhong-Ying Zhang, Bing-Hui Pan, Wen-Tao Jiang

Jun-Jie Li, Jian Yang, Jia-Ming Shang, Jiang Li, Chi-Yi Chen, Department of Liver Transplantation, Tianjin First Center Hospital, Tianjin 300192, China

Yan Xie, Wen-Tao Jiang, Department of Liver Transplantation, First Central Hospital of Tianjin Medical University, Tianjin 300380, China

Li-Na Liu, Zhong-Ying Zhang, Bing-Hui Pan, Hua Rong Ke Chuang Biotechnology (Tian Jin) CO. Ltd, Tianjin 300192, China

Co-first authors: Jun-Jie Li and Jian Yang.

Co-corresponding authors: Yan Xie and Wen-Tao Jiang.

Author contributions: Li JJ and Yang J contributed equally to this article as co-first authors; Li JJ and Jiang WT conceived the study and performed critical revision of the manuscript for important intellectual content; Xie Y, Shang JM, Li J, Chen CY, Liu LN, Zhang ZY, and Pan BH collected the data; Yang J drafted the manuscript; Jiang WT and Xie Y contributed equally to this article as co-corresponding authors; and all authors thoroughly reviewed and endorsed the final manuscript.

AI contribution statement: We have written the response to reviewers from scratch, without any AI involvement whatsoever. It is assured that no AI software (DeepSeek, ChatGPT, etc.) was used in preparing this response.

Supported by Key Project of Scientific Research Plan of Tianjin Municipal Education Commission, No. 2024ZXZD010; Project of Tianjin Science and Technology Bureau Applied Basic Research, No. 23JCYBJC01800; and Beijing Hepatobiliary Sympathy Foundation Special Fund, No. iGandan-1082025-RGG009.

Institutional animal care and use committee statement: All procedures involving animals were reviewed and approved by the Institutional Animal Care and Use Committee of A-Jentec Institutional, approval No. ZH20231207P.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

ARRIVE guidelines statement: The authors have read the ARRIVE guidelines, and the manuscript was prepared and revised according to the ARRIVE guidelines.

Data sharing statement: The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.

Corresponding author: Wen-Tao Jiang, Dean, Chief Physician, Full Professor, Department of Liver Transplantation, First Central Hospital of Tianjin Medical University, No. 2 Baoshan West Road, Xiqing District, Tianjin 300380, China. jiangwentao@nankai.edu.cn

Received: February 25, 2026
Revised: March 22, 2026
Accepted: May 25, 2026
Published online: August 27, 2026
Processing time: 173 Days and 13.1 Hours

Abstract

BACKGROUND

Portal vein reconstruction is a critical step in liver transplantation. Hand-sutured anastomosis is time-consuming and may predispose to malalignment, needle-hole bleeding, and stenosis. A sutureless, mechanically coupled anastomotic principle that minimizes mechanical trauma and foreign body reaction could improve healing.

AIM

To compare a microvascular anastomotic coupler (embodying the sutureless principle) with conventional hand-suturing for portal vein reconstruction in a translational porcine orthotopic liver transplantation model.

METHODS

Forty male pigs (weighing 60-66 kg) were randomized (1:1) to coupler or hand-sutured portal vein anastomosis. The primary endpoint was anastomosis time. Secondary endpoints included 12-week patency, portal venous velocity (Doppler), liver biochemistry, and detailed histopathological analysis of the anastomotic site. Histological evaluation was performed using an artificial intelligence-assisted workflow (ChatGPT-4.0 with vision) for pre-segmentation and provisional quantification, with all outputs independently reviewed and corrected by two blinded observers. Final analyses were conducted using the observer-verified values.

RESULTS

Coupler use halved anastomosis time (12.4 ± 2.2 minutes vs 24.5 ± 3.8 minutes, P < 0.001). Twelve-week patency was comparable (100% vs 95%, P = 1.000). Portal venous velocity remained stable and was consistently higher in the coupler group (immediate: 20.5 ± 3.1 cm/second vs 18.3 ± 2.6 cm/second, P = 0.020; 12-week: 22.9 ± 3.4 cm/second vs 20.8 ± 2.8 cm/second, P = 0.040). Liver function tests showed no significant between-group differences. Histology revealed significantly fewer inflammatory cells (macrophages, lymphocytes, and plasma cells) and a smaller necrotic area in the coupler group (e.g., macrophages: 5.3 ± 1.1 vs 8.6 ± 1.5 per high power field, P < 0.001), along with lower inflammation and tissue disorganization scores (both P < 0.001).

CONCLUSION

In a porcine liver transplantation model, the microvascular anastomotic coupler enables faster portal vein reconstruction while maintaining excellent patency, favorable hemodynamics, and superior histologic healing. These findings support its translational potential for clinical use.

Keywords: Microvascular anastomotic coupler; Sutureless anastomosis; Portal vein reconstruction; Porcine model; Liver transplantation; Artificial intelligence-assisted histopathology

Core Tip: This randomized porcine orthotopic liver transplantation study evaluates a microvascular anastomotic coupler for sutureless portal vein reconstruction. Compared with hand-sewn anastomosis, the coupler shortened anastomosis time by about 12 minutes while maintaining 12-week patency and portal hemodynamics. Quantitative, artificial intelligence-assisted (human-verified) histopathology demonstrated fewer inflammatory cells and smaller necrotic areas around the anastomosis, supporting a favorable local tissue response. These findings indicate that a simple, standardized coupler can reduce warm ischemia and technical variability without sacrificing vascular integrity, offering a practical pathway to streamline portal reconstruction in liver transplantation.