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Ahrens E, Caputo G, Planinsic R, Zanza C, Longhitano Y. The role of veno-venous bypass in liver transplant. Curr Opin Anaesthesiol 2025:00001503-990000000-00300. [PMID: 40492659 DOI: 10.1097/aco.0000000000001504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2025]
Abstract
PURPOSE OF REVIEW Veno-venous bypass (VVB) ensures end-organ perfusion and minimizes splanchnic venous congestion during liver transplant procedures. The adoption of the piggyback technique, where flow through the inferior vena cava is preserved, has prompted a decline in the routine use of VVB. Meanwhile, recommendations on VVB use in liver transplantation remain equivocal. This article explores the clinical implications of VVB use in liver transplantation and offers a comprehensive analysis of its benefits and risks in the context of recent surgical advancements. RECENT FINDINGS Evidence indicates that patients undergoing complex procedures or with baseline renal dysfunction may benefit from VVB for conventional liver resection, emphasizing the need for careful patient selection. By contrast, small, retrospective studies suggest lower transfusion requirements and improved graft survival when the piggyback approach was used without VVB, but evidence remains sparse. While direct bypass cannulation-associated complications remain a concern, technical advancements have made VVB use increasingly safe. SUMMARY In conclusion, VVB remains an important tool in selected, high-acuity patients, but offers limited benefit in more stable patients undergoing piggyback liver resection. Large-scale randomized studies are needed to elucidate the benefit of VVB in selected patient populations undergoing procedures with different surgical approaches.
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Affiliation(s)
- Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Giorgia Caputo
- Department of Anesthesia and Intensive Care, San Luigi Gonzaga Hospital, Turin, Orbassano, Italy
| | - Raymond Planinsic
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christian Zanza
- Department of Systems Medicine, Geriatric Medicine Residency Program, University of Rome "Tor Vergata", Rome, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Bezinover D, Mukhtar A, Wagener G, Wray C, Blasi A, Kronish K, Zerillo J, Tomescu D, Pustavoitau A, Gitman M, Singh A, Saner FH. Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA. Transplantation 2021; 105:2184-2200. [PMID: 33534523 DOI: 10.1097/tp.0000000000003642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA. Represents ILTS and LICAGE
| | - Ahmed Mukhtar
- Department of Anesthesia and Surgical Intensive Care, Cairo University, Almanyal, Cairo, Egypt. Represents LICAGE
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, NY. Represents SATA and ILTS
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA. Represents SATA
| | - Annabel Blasi
- Department of Anesthesia, IDIBAPS (Institut d´investigació biomèdica Agustí Pi i Sunyé) Hospital Clinic, Villaroel, Barcelona, Spain. Represents LICAGE and ILTS
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. Represents SATA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY. Represents SATA and ILTS
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania. Represents LICAGE
| | - Aliaksei Pustavoitau
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, MD. Represents ILTS
| | - Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL. Represents SATA and ILTS
| | - Anil Singh
- Department of Liver Transplant and GI Critical Care, Sir HN Reliance Foundation Hospital, Cirgaon, Mumbai, India. Represents ILTS
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany. Represents LICAGE
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Single Orifice Outflow Reconstruction: Refining the Venous Outflow in Modified Right Lobe Live Donor Liver Transplantation. J Gastrointest Surg 2021; 25:1962-1972. [PMID: 32808136 DOI: 10.1007/s11605-020-04776-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/08/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND MHV reconstruction is essential to avoid anterior sector congestion in adult live donor liver transplantation (LDLT) using a modified right lobe graft. AIMS The objective of this study is to evaluate the graft and patient outcomes with single orifice outflow reconstruction technique (SORT) (RHV + neo-MHV combined reconstruction on IVC) vs. dual outflow reconstruction technique (DORT) (RHV and neo-MHV separately reconstructed on IVC) in a modified right lobe LDLT. METHODS Prospectively collected data of consecutive patients undergoing LDLT from June 2011 to August 2018 were analyzed. The patients were divided into two groups: SORT (n = 207) and DORT (n = 108). The perioperative morbidity and mortality were compared between two groups. RESULTS The two groups were comparable in baseline preoperative characteristics. Intraoperatively, warm ischemia time (27 vs. 45 min, p < 0.001), anhepatic phase (132 vs. 159 min, p < 0.001), and operative time (680 vs. 840 min, p < 0.001) were significantly shorter in SORT group. SORT group also had significantly lower GRWR (0.92 vs. 1.06, p < 0.001) and higher portal flow (2.4 vs. 2.7 L/min, p = 0.02). Postoperatively, SORT group had lower peak AST (177 vs. 209 IU/L, p < 0.001), ALT (163 vs. 189 IU/L, p = 0.004), creatinine levels (0.98 vs. 1.10, p = 0.01), rate of severe sepsis (13.7% vs. 22.9%, p = 0.03), major morbidity (50.7% vs. 62.6%, p = 0.03), shorter ICU (9 vs. 14 days, p < 0.001), and hospital stay (21 vs. 26 days, p = 0.03). Overall survival rates were comparable. CONCLUSION A SORT leads to improved early graft function and perioperative morbidity in modified right lobe LDLT in spite of having lower GRWR and higher portal flow.
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Reshetnyak VI, Zhuravel SV, Kuznetsova NK, Pisarev VМ, Klychnikova EV, Syutkin VЕ, Reshetnyak ТM. The System of Blood Coagulation in Normal and in Liver Transplantation (Review). GENERAL REANIMATOLOGY 2018; 14:58-84. [DOI: 10.15360/1813-9779-2018-5-58-84] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The review dwells on the problem of hemostatic disorders in patients undergoing liver transplantation and their correction in the perioperative period. The physiology of the hemostatic system, disorders of the blood coagulation system in patients at various stages of liver transplantation, correction of hemostatic disorders during and after orthotopic liver transplantation are discussed. Liver transplantation is performed in patients with liver diseases in the terminal stage of liver failure. At the same time, changes in the hemostatic system of these patients pose a significant risk of developing bleeding and/or thrombosis during and after liver transplantation. The hypothesis is suggested that the personalized correction of hemostasis disorder in liver transplantation should be based on considerating the nosological forms of the liver damage, mechanisms of development of recipient’s hemostatic disorders, and the stage of the surgery.
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Affiliation(s)
- V. I. Reshetnyak
- V. A. Negovsky Research Institute of General Reanimatology, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology
| | - S. V. Zhuravel
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
| | - N. K. Kuznetsova
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
| | - V. М. Pisarev
- V. A. Negovsky Research Institute of General Reanimatology, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology
| | - E. V. Klychnikova
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
| | - V. Е. Syutkin
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
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Koh PS, Chan SC. Adult-to-adult living donor liver transplantation: Operative techniques to optimize the recipient's outcome. J Nat Sci Biol Med 2017; 8:4-10. [PMID: 28250667 PMCID: PMC5320821 DOI: 10.4103/0976-9668.198356] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Adult-to-adult living donor liver transplantation (LDLT) is widely accepted today with good outcomes and safety reported worldwide for both donor and recipient. Nonetheless, it remained a highly demanding technical and complex surgery if undertaken. The last two decades have seen an increased in adult-to-adult LDLT following our first report of right lobe LDLT in overcoming graft size limitation in adults. In this article, we discussed the operative techniques and challenges of adult right lobe LDLT incorporating the middle hepatic vein, which is practiced in our center for the recipient operation. The various issues and challenges faced by the transplant surgeon in ensuring good recipient outcome are explored and discussed here as well. Hence, it is important to understand that a successful recipient operation is dependent of multifactorial events starting at the preoperative stage of planning, understanding the intraoperative technical challenges and the physiology of flow modulation that goes hand-in-hand with the operation. Therefore, one needs to arm oneself with all the possible knowledge in overcoming these technical challenges and the ability to be flexible and adaptable during LDLT by tailoring the needs of each patient individually.
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Affiliation(s)
- Peng Soon Koh
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - See Ching Chan
- Department of Surgery, The University of Hong Kong, Hong Kong, SAR, China
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Chan SC, Cheung TT, Chan ACY, Chok KSH, Sharr WW, Fung JYY, Liu CL, Fan ST, Lo CM. New insights after the first 1000 liver transplantations at The University of Hong Kong. Asian J Surg 2016; 39:202-210. [PMID: 26143970 DOI: 10.1016/j.asjsur.2015.03.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 03/09/2015] [Accepted: 03/10/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/OBJECTIVE One thousand liver transplantations have been performed at the only liver transplant center in Hong Kong over a period of 22 years, which covered the formative period of living donor liver transplantation. These 1000 transplantations, which marked the journey of liver transplantation from development to maturation at the center, should be educational. This research was to study the experience and to reflect on the importance of technical innovations and case selection. METHODS The first 1000 liver transplantations were studied. Key technical innovations and surgical therapeutics were described. Recipient survival including hospital mortality was analyzed. Recipient survival comparison was made for deceased donor liver transplantation and living donor liver transplantation indicated by hepatocellular carcinoma and other diseases. RESULTS Among the 1000 transplantations, 418 used deceased donor grafts and 582 used living donor grafts. With the accumulation of experience, hospital mortality improved to < 2% in the past 2 years. In the treatment of diseases other than hepatocellular carcinoma, living donor liver transplantation was superior to deceased donor liver transplantation, with a 10-year recipient survival around 90%. CONCLUSION Transplant outcomes have been improving consistently over the series, with a very low hospital mortality and a predictably high long-term survival.
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Affiliation(s)
- See Ching Chan
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.
| | - Tan To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Albert C Y Chan
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Kenneth S H Chok
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - William W Sharr
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - James Y Y Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Chi Leung Liu
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Sheung Tat Fan
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Chung Mau Lo
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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Cleland S, Corredor C, Ye JJ, Srinivas C, McCluskey SA. Massive haemorrhage in liver transplantation: Consequences, prediction and management. World J Transplant 2016; 6:291-305. [PMID: 27358774 PMCID: PMC4919733 DOI: 10.5500/wjt.v6.i2.291] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 03/16/2016] [Accepted: 04/11/2016] [Indexed: 02/05/2023] Open
Abstract
From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity (need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both pro- and anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shown improvements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.
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8
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Ingraham CR, Montenovo M. Interventional and Surgical Techniques in Solid Organ Transplantation. Radiol Clin North Am 2016; 54:267-80. [DOI: 10.1016/j.rcl.2015.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Chu KKW, Chan SC, Sharr WW, Chok KSH, Dai WC, Lo CM. Low-volume deceased donor liver transplantation alongside a strong living donor liver transplantation service. World J Surg 2014; 38:1522-1528. [PMID: 24385193 DOI: 10.1007/s00268-013-2437-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND At our center, living donor liver transplantation (LDLT) is the main workload supported by a strong, mature service. Deceased donor liver transplantation (DDLT) is performed but in small volume. This study aimed to review the results of a low-volume DDLT service alongside a strong LDLT service. METHODS Consecutive DDLTs for adults performed from 1991 to 2009 were reviewed. The 1st to the 50th DDLTs were categorized as Era I cases, and the rest were Era II cases. The outcomes of the DDLTs were analyzed and compared with those achieved overseas. RESULTS Eras I and II consisted of 59 and 183 DDLTs, respectively. All donors were brain-dead and heart-beating with a median age of 49 years (range 7-76 years). Among the 242 DDLTS, 30.2 % were on a high-urgency basis and 15.3 % were for hepatocellular carcinoma. The patients had a median model for end-stage liver disease score of 21 (range 6-40), and most (67.8 %) were hepatitis B virus carriers. Before transplantation, 16.1 % of the patients were in the intensive care unit and 30.2 % were in the hospital. The hospital mortality rate dropped from 13.6 % (8/59) during Era I to 3.8 % (7/183) during Era II (p = 0.012). For Era I, the 1-, 3-, and 5-year survival rates were 84.7, 79.7, and 76.3 %, respectively, which improved to 92.9, 89.0 and 87.2 % for Era II (p = 0.026). CONCLUSIONS The recipient survival of this series compares favorably with contemporary series. It is shown that a low-volume DDLT service alongside a strong LDLT service can have excellent results.
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Affiliation(s)
- Kevin K W Chu
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
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Chan SC, Sharr WW, Chan ACY, Chok KSH, Lo CM. Rescue Living-donor Liver Transplantation for Liver Failure Following Hepatectomy for Hepatocellular Carcinoma. Liver Cancer 2013; 2:332-337. [PMID: 24400220 PMCID: PMC3881315 DOI: 10.1159/000343848] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Liver failure following major hepatectomy for hepatocellular carcinoma is a known but uncommon mode of early treatment failure. When post-hepatectomy liver failure becomes progressive, the only effective treatment for rescuing the patient is liver transplantation. Deceased-donor liver transplantation in this situation is often not feasible because of the shortage of deceased-donor liver grafts. Proceeding with living-donor liver transplantation is an ethical challenge because of the possibility of donor coercion. In addition, tumor status, as confirmed by histopathological examination of the resected specimen, may indicate aggressive cancer that warns against rescue transplantation because of the increased chance of tumor recurrence. Here we describe four cases of rescue living-donor liver transplantation for liver failure after hepatectomy for hepatocellular carcinoma. The patients all survived the transplantation and were free from tumor recurrence after follow-up periods ranging from 6 months to 9 years. Our experience has shown that rescue living-donor liver transplantation for post-hepatectomy liver failure is feasible. Tumor status should be considered carefully because large tumors and tumors with macrovascular invasion are strong contraindications to rescue living-donor liver transplantation.
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Affiliation(s)
- See Ching Chan
- Department of Surgery, The University of Hong Kong, Hong Kong, SAR, China
- State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, SAR, China
| | - William Wei Sharr
- Department of Surgery, The University of Hong Kong, Hong Kong, SAR, China
| | | | | | - Chung Mau Lo
- Department of Surgery, The University of Hong Kong, Hong Kong, SAR, China
- State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, SAR, China
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Experience of Combined Liver-Kidney Transplantation for Acute-on-Chronic Liver Failure Patients With Renal Dysfunction. Transplant Proc 2013; 45:2307-13. [DOI: 10.1016/j.transproceed.2013.02.127] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 01/06/2013] [Accepted: 02/16/2013] [Indexed: 12/25/2022]
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Miranda LEC, de Melo PSV, Sabat BD, Tenório AL, Lima DL, Neto OCLF, Amorim AG, Fernandez JL, de Macedo FIB, Lacerda CM. Orthotopic liver transplantation without venovenous bypass: 125 cases from a single center. Transplant Proc 2013; 44:2416-22. [PMID: 23026610 DOI: 10.1016/j.transproceed.2012.07.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This study analyzed a 10-year single-center experience in orthotopic liver transplantation (OLT) without venovenous bypass (VVB). METHODS We retrospectively analysed a nonrandomized series (1999-2008) of 125 adult OLT patients without VVB. RESULTS The main causes of liver failure were viral hepatitis (n = 39), alcoholic liver disease (n = 22), and liver cancer (n = 17). One-year survival was 76.4%. The most common postoperative complications were bile duct stenosis (n = 12), postoperative bleeding (n = 8), hepatic artery thrombosis (n = 7), and primary liver failure (n = 6). Twelve patients required hemodialysis and four underwent retransplantations of the liver. Fourteen patients died before postoperative day 30(th). Univariate analysis showed significant differences between patients who did and did not survive 30 days among donor death diagnoses (P = .05), red blood cell units transfused (P = .03), aspartate aminotranferase on the first postoperative day (P = .002), ABO type (P = .04), time of orotracheal intubation (P = .001), hemodialysis (P = .001), and period of postoperative vasoactive drug use (P = .006). The total length of orotracheal tube intubation showed a significant independent association with mortality before 30 days (P < .001). CONCLUSION OLT without VVB can be safely performed even in severe cases of chronic liver failure.
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Affiliation(s)
- L E C Miranda
- Department of Surgery and Liver Transplantation, Oswaldo Cruz University Hospital, University of Pernambuco, Brazil.
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Paolo F, Marialuisa B, Stefania B, Helmut G, Moira M, Cristiana C, Carlo O. Blood loss, predictors of bleeding, transfusion practice and strategies of blood cell salvaging during liver transplantation. World J Hepatol 2013; 5:1-15. [PMID: 23383361 PMCID: PMC3562721 DOI: 10.4254/wjh.v5.i1.1] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 01/19/2013] [Indexed: 02/06/2023] Open
Abstract
Blood loss during liver transplantation (OLTx) is a common consequence of pre-existing abnormalities of the hemostatic system, portal hypertension with multiple collateral vessels, portal vein thrombosis, previous abdominal surgery, splenomegaly, and poor “functional” recovery of the new liver. The intrinsic coagulopathic features of end stage cirrhosis along with surgical technical difficulties make transfusion-free liver transplantation a major challenge, and, despite the improvements in understanding of intraoperative coagulation profiles and strategies to control blood loss, the requirements for blood or blood products remains high. The impact of blood transfusion has been shown to be significant and independent of other well-known predictors of posttransplant-outcome. Negative effects on immunomodulation and an increased risk of postoperative complications and mortality have been repeatedly demonstrated. Isovolemic hemodilution, the extensive utilization of thromboelastogram and the use of autotransfusion devices are among the commonly adopted procedures to limit the amount of blood transfusion. The use of intraoperative blood salvage and autologous blood transfusion should still be considered an important method to reduce the need for allogenic blood and the associated complications. In this article we report on the common preoperative and intraoperative factors contributing to blood loss, intraoperative transfusion practices, anesthesiologic and surgical strategies to prevent blood loss, and on intraoperative blood salvaging techniques and autologous blood transfusion. Even though the advances in surgical technique and anesthetic management, as well as a better understanding of the risk factors, have resulted in a steady decrease in intraoperative bleeding, most patients still bleed extensively. Blood transfusion therapy is still a critical feature during OLTx and various studies have shown a large variability in the use of blood products among different centers and even among individual anesthesiologists within the same center. Unfortunately, despite the large number of OLTx performed each year, there is still paucity of large randomized, multicentre, and controlled studies which indicate how to prevent bleeding, the transfusion needs and thresholds, and the “evidence based” perioperative strategies to reduce the amount of transfusion.
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Vieira de Melo PS, Miranda LEC, Batista LL, Neto OCLF, Amorim AG, Sabat BD, Cândido HLL, Adeodato LCL, Lemos RS, Carvalho GL, Lacerda CM. Orthotopic liver transplantation without venovenous bypass using the conventional and piggyback techniques. Transplant Proc 2011; 43:1327-33. [PMID: 21620122 DOI: 10.1016/j.transproceed.2011.03.061] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Orthotopic liver transplantation is a widely used procedure for the treatment of irreversible liver diseases for which there is no possibility of medical treatment. When this procedure is performed by the conventional technique, the retrohepatic vena cava is removed along with the native liver. The inferior vena cava (IVC) remains clamped until the revascularization of the graft, and in this period there is a reduction in the venous return, which may induce a fall by up to 50% in the cardiac output with hemodynamic instability and a fall in renal perfusion pressure. The use of a portal-femoral-axillary venovenous bypass system, in which the blood from the femoral and portal veins returns to the heart via the axillary vein propelled by a centrifugal pump, is intended to minimize the effects of the IVC clamping. In the piggyback (PB) technique, the native liver is removed and the IVC of the recipient is preserved and only partially clamped. We have employed both techniques without the use of venovenous bypass for 10 years. The objective of this study was to compare the results obtained from the use of the two techniques. PATIENTS AND METHODS A retrospective analysis was performed of 195 patients transplanted between 1999 and 2008: 125 by the conventional technique and 70, the PB technique. The intraoperative parameters were analyzed (surgical time, ischemia time, use of blood products, and diuresis), as well as intensive care support (duration of stay in intensive care unit and use of vasoactive drugs), period of intubation, length of hospital stay, renal function, graft function, postoperative complications, retransplantation, and patient survival. RESULTS The PB group showed a reduction in surgical time, warm ischemia time, the use of packed red blood cells concentrates, and fresh frozen plasma, as well as mortality at 30 days (P<.05). There were no differences in relation to cold ischemia time, intraoperative diuresis; length of stay and use of vasoactive drugs in the intensive care unit; the period of intubation; the duration of hospital stay; the renal function; the graft function; the need for reoperation; the incidence of sepsis, biliary complications, vascular complications; need for retransplantation; and 1-year mortality. The cumulative survival rate at 1 year was significantly better among the PB patients. CONCLUSION Orthotopic liver transplantation can be performed without venovenous bypass with good results, using either the conventional technique or the PB technique. Provided that there is no technical contraindication and a long ischemia period is not foreseen, the PB technique should be the technique of choice.
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Affiliation(s)
- P S Vieira de Melo
- Department of Surgery and Liver Transplantation, Oswaldo Cruz University Hospital, University of Pernambuco, Recife City, Pernambuco State, Brazil.
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15
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Chan SC, Lo CM, Ng KKC, Ng IOL, Yong BH, Fan ST. Portal inflow and pressure changes in right liver living donor liver transplantation including the middle hepatic vein. Liver Transpl 2011; 17:115-21. [PMID: 21280183 DOI: 10.1002/lt.22034] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The middle hepatic vein may be included in right liver living donor liver transplantation (LDLT) to optimize hepatic venous outflow. We studied the graft's ability to relieve portal hypertension and accommodate portal hyperperfusion with portal manometry and ultrasonic flowmetry. Surgical outcomes with respect to portal hemodynamometry were also investigated. The ages of the recipients and donors for 46 consecutive LDLT procedures were 50 (range, 16-66 years) and 31 years (range, 18-54 years), respectively. The graft to standard liver volume ratio was 47.4% (range, 32.4%-69.0%). The hospital mortality rate was 4.4% as 2 recipients died from a subarachnoid hemorrhage and sepsis. The portal pressure dropped by 8 mm Hg (range, -7 to 19 mm Hg) from 23 (range, 8-37 mm Hg) to 14 mm Hg (range, 10-26 mm Hg) after graft implantation. The portal inflow positively correlated with the portal pressure before native liver hepatectomy (R(2) = 0.305, P = 0.001) and not with the graft size. The portal inflow increased from 81 mL/minute/100 g (range, 35-210 mL/minute/100 g) before donor right hepatectomy to 318 mL/minute/100 g (range, 102-754 mL/minute/100 g) after graft implantation. The graft portal inflow had a positive linear correlation with the recipient portal pressure before native liver total hepatectomy (R(2) = 0.261, P = 0.001) but not after graft implantation, and it had a negative correlation with the graft to standard liver volume ratio (R(2) = 0.247, P = 0.001). Only 1 of the graft biopsies showed moderate sinusoidal congestion. Twelve recipients had Clavien grade 2+ complications that were not related to the portal inflow and pressure or graft size. Right liver LDLT including the middle hepatic vein effectively lowered the recipient portal pressure by allowing unimpeded venous outflow.
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Affiliation(s)
- See Ching Chan
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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16
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Aseni P, Lauterio A, Slim AO, Giacomoni A, Lamperti L, De Carlis L. Life-saving super-urgent liver transplantation with replacement of retrohepatic vena cava by dacron graft. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2010; 2010:828326. [PMID: 20811479 PMCID: PMC2926580 DOI: 10.1155/2010/828326] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Revised: 05/31/2010] [Accepted: 06/26/2010] [Indexed: 02/07/2023]
Abstract
We describe a modified technique of side-to-side cavo-cavostomy by Dacron interposition prosthesis during a super urgent liver transplantation. A liver graft from a deceased donor was immediately requested on a top priority basis as a consequence of massive bleeding during extended left hepatectomy for a huge hepatic haemangioma arising from the caudate lobe. Veno-venous bypass was employed during anhepatic phase but it was disconnected due to severe fibrinolysis and hypothermia. A porto-caval shunt was performed and the inferior vena cava outflow was restored by a Dacron interposition prosthesis. A liver graft from a deceased donor was available 16 hours later. Due to the shortness of the vena cava of the donor liver graft, the removal of the Dacron graft was impossible and a modified side-to-side cavo-cavostomy between the Dacron interposition graft and the vena cava of the donor liver was than performed. Liver transplantation was uneventful and the patient is doing well 25 months after the surgical procedure. Although the use of synthetic vascular prosthesis should usually be discouraged during organ transplantation, its exceptional use during liver transplantation is possible with long-term good results.
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Affiliation(s)
- Paolo Aseni
- Department of Surgery, Liver Transplantation Unit, Niguarda “Cà Granda” Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
- Department of Genaral Surgery, Hepatobiliary and Transplant Unit, Niguarda “Cà Granda” Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Andrea Lauterio
- Department of Surgery, Liver Transplantation Unit, Niguarda “Cà Granda” Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Abdallah Omar Slim
- Department of Surgery, Liver Transplantation Unit, Niguarda “Cà Granda” Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Alessandro Giacomoni
- Department of Surgery, Liver Transplantation Unit, Niguarda “Cà Granda” Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Luca Lamperti
- Department of Surgery, Liver Transplantation Unit, Niguarda “Cà Granda” Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Luciano De Carlis
- Department of Surgery, Liver Transplantation Unit, Niguarda “Cà Granda” Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
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17
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Chan SC, Lo CM, Ng KKC, Fan ST. Alleviating the burden of small-for-size graft in right liver living donor liver transplantation through accumulation of experience. Am J Transplant 2010; 10:859-867. [PMID: 20148811 DOI: 10.1111/j.1600-6143.2010.03017.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The issue of small-for-size graft (SFSG) containing the middle hepatic vein in right liver living donor liver transplantation from 1996 to 2008 (n = 320) was studied. Characteristics of donors, grafts and recipients were comparable between Era I (first 50 cases) and Era II (next 270 cases) except that the median model for end-stage liver disease (MELD) score was higher in Era I (29 vs. 24; p = 0.024). The median graft to standard liver volume ratio (G/SLV) in Era I was 49.0% (range, 32.8-86.2%), versus 49.3% (range, 28.4-89.4%) in Era II (p = 0.498). Hospital mortality rate, the study endpoint, dropped from 16.0% (8/50) in Era I to 2.2% (6/270) in Era II (p = 0.000). Univariate analysis showed that MELD score (p = 0.002), pretransplant hepatorenal syndrome (p = 0.000) and Era I (p = 0.000) were significant in hospital mortality. Logistic regression analysis showed that only Era I (relative risk 9.758; 95% confidence interval, 2.885-33.002; p = 0.000) was significant. In Era I, G/SLV<40% had a relative risk of 7.8 (95% confidence interval, 1.225-49.677; p = 0.030). The hospital mortality rates for G/SLV<40% were 50% (3/6) and 1.9% (1/52) in Era I and II respectively. In conclusion, through accumulation of experience, SFSG became less important as a factor in hospital mortality.
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Affiliation(s)
- S C Chan
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, China
| | - C M Lo
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, China
| | - K K C Ng
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, China
| | - S T Fan
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, China
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18
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Chan SC, Lo CM, Ng KK, Chok KS, Fan ST. Simplifying hepatic venous outflow reconstruction in sequential living donor liver transplantation. Liver Transpl 2009; 15:1514-1518. [PMID: 19877255 DOI: 10.1002/lt.21896] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The native liver of a familial amyloidotic polyneuropathy recipient who undergoes living donor liver transplantation used as a graft for sequential liver transplantation does not include the inferior vena cava. Implantation of this whole liver graft to a second recipient could be simplified by borrowing the experience from right liver living donor liver transplantation. With careful release of the hepatic vein from its surrounding adventitia mainly by sharp dissections, adequate lengths of these veins could be attained without compromising the native inferior vena cava. Following venoplasty of the right and middle/left hepatic vein stumps, the single cuff of the hepatic veins is anastomosed to the inferior vena cava without interpositional venous graft or patch. Satisfactory venous outflow is reliably achieved because this is the most direct outflow tract.
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Affiliation(s)
- See Ching Chan
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong, China
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19
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Chan SC, Lo CM, Chik BH, Chow LC, Fan ST. Flowmetry-based portal inflow manipulation for a small-for-size liver graft in a recipient with spontaneous splenorenal shunt. Clin Transplant 2009; 24:410-4. [PMID: 19807745 DOI: 10.1111/j.1399-0012.2009.01100.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We report a case of living donor liver transplantation using a small-for-size graft (SFSG) with graft to estimated standard liver volume of only 28% in a recipient with spontaneous splenorenal shunt and demonstrate the value of intraoperative ultrasonic flowmetry. Despite an SFSG, the graft was underperfused. This was recognized by flowmetry and was rectified by ligation of the splenorenal shunt.
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Affiliation(s)
- See Ching Chan
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong, China
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20
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Chan AC, Fan ST, Lo CM, Liu CL, Chan SC, Ng KK, Yong BH, Chiu A, Lam BK. Liver transplantation for acute-on-chronic liver failure. Hepatol Int 2009; 3:571-81. [PMID: 19680733 PMCID: PMC2790588 DOI: 10.1007/s12072-009-9148-8] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2009] [Revised: 07/23/2009] [Accepted: 08/03/2009] [Indexed: 12/13/2022]
Abstract
Purpose To evaluate the outcome of liver transplantation for acute-on-chronic liver failure. Patients and methods From November 1991 to December 2007, 517 patients underwent liver transplantation at Queen Mary Hospital, Hong Kong. Among them, 149 had acute-on-chronic liver failure as defined in the recent Asian Pacific Association for the Study of Liver Consensus Meeting. Their clinical data were reviewed and their survival outcomes were compared with those of patients who underwent liver transplantation for fulminant hepatic failure and for cirrhosis only in the same period. Results The patients with acute-on-chronic liver failure included 50 patients having acute exacerbation of chronic hepatitis B and 99 cirrhotic patients with acute deterioration. Their median model for end-stage liver disease scores were 35 and 37, respectively. Preoperative infection (35%), hepatorenal syndrome (38%), and respiratory failure (28.8%) were common. One hundred and three patients received living donor liver grafts and 46 patients received deceased donor liver grafts. The hospital mortality rate was 4.7%. The 5-year survival rates were 93.2% for patients with acute exacerbation of chronic hepatitis B and 90.5% for cirrhotic patients with acute deterioration. The results were similar to those of the patients with fulminant hepatic failure (n = 37) and the patients having cirrhosis only (n = 301). Conclusions Liver transplantation for acute-on-chronic liver failure is life-saving, and the survival rates it attains are similar to those attained by transplantation for other liver conditions.
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Affiliation(s)
- Albert C Chan
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
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21
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Chan SC, Fan ST, Lo CM, Liu CL, Wei WI, Chik BHY, Wong J. A decade of right liver adult-to-adult living donor liver transplantation: the recipient mid-term outcomes. Ann Surg 2008; 248:411-9. [PMID: 18791361 DOI: 10.1097/sla.0b013e31818584e6] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We analyzed a single center's experience over a decade of right liver living donor liver transplantation (RLDLT). SUMMARY BACKGROUND DATA To define the donor risk and recipient benefit ratio, midterm outcome of this life-saving treatment modality ought to be known. METHODS Consecutive patients from 9 May 1996 were included. Era I comprised the first 50 patients and Era II comprised the remaining 184 patients. Their midterm outcomes were compared with patients receiving deceased donor liver transplantation (DDLT) of the same period in the same center. RESULTS With a median follow-up of 48 months, the 1-, 3-, and 5-year overall survival rates were 93.2%, 85.7%, and 82.4%, respectively and were comparable with those of DDLT (n = 131) (90.1%, 87.7%, and 85.2%) (P = 0.876). Hospital mortality decreased from 16% in Era I to 2.2% in Era II (P = 0.000). Reduced hospital mortality improved the overall survival rates from Era I to Era II (78%, 74%, and 72% vs. 97.3%, 88.7%, and 85.1%, respectively) (P = 0.003). The 5-year survival rate of recipients with hepatocellular carcinoma (HCC) (n = 65) was 65.7%. Starting from Era II, excellent 5-year survival of recipients without HCC was achieved as compared with DDLT in the same period (93.4% vs. 88.2%) (P = 0.493). The 5-year survival rates of recipients with HCC within the Milan criteria of Era II and DDLT in the same period were 72.0% and 100%, respectively (P = 0.091). Multivariate analysis indicated that only Era I (relative risk = 2.606; P = 0.005) and pretransplant HCC (relative risk = 2.729; P = 0.002) adversely affected overall survival. CONCLUSIONS High midterm survivals were achieved by reduction of hospital mortality through accumulation of experience and transplanting recipients with low chance of recurrence of HCC. RLDLT could be considered as a legitimate alternative to DDLT.
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Affiliation(s)
- See Ching Chan
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong, China
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22
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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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23
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Chan SC, Fan ST, Lo CM, Liu CL. Effect of side and size of graft on surgical outcomes of adult-to-adult live donor liver transplantation. Liver Transpl 2007; 13:91-8. [PMID: 17192891 DOI: 10.1002/lt.20987] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
By virtue of size, the right liver graft has become the workhorse of adult-to-adult live donor liver transplantation (ALDLT). Although favorable results of left liver ALDLT have also been reported, a head-to-head comparison of these 2 graft types both containing the middle hepatic vein had not been made. In this study, we compared the outcomes of 29 right liver and 16 left liver ALDLTs of comparable graft weight to recipient estimated standard liver volume ratio (GW/ESLV, 36.9% and 36.4%, respectively). All liver grafts contained the middle hepatic vein. The Model for End-Stage Liver Disease (MELD) score and urgency for transplantation of both groups were similar. Postoperatively, left liver donors had significantly lower international normalized ratios and serum total bilirubin levels and no complications. Although the rate of return of international normalized ratios for recipients of both groups were comparable, left liver recipients had significantly higher serum total bilirubin and serum aminotransferase levels. Intensive care unit stay of the left liver recipients was longer than that of the right liver recipients (8.5 days versus 4 days, P = 0.007). Hospital mortality was 6.9% (2/29) for the right liver group and 18.8% (3/16) for the left liver group (P = 0.330). Safety profile of donor left hepatectomy was higher. However, despite similar GW/ESLV, the more arduous recovery and higher mortality rate of left liver recipients raise the caution of assuming the gram-to-gram equivalence of right and left liver grafts.
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Affiliation(s)
- See Ching Chan
- Department of Surgery, The University of Hong Kong, Pokfulam, Hong Kong, China
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24
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Abstract
Live donor liver transplantation (LDLT) was initiated in 1988 for children recipients. Its application to adult recipients was limited by graft size until the first right liver LDLT was performed in Hong Kong in 1996. Since then, right liver graft has become the major graft type. Despite rapid adoption of LDLT by many centers, many controversies on donor selection, indications, techniques, and ethics exist. With the recent known 11 donor deaths around the world, transplant surgeons are even more cautious than the past in the evaluation and selection of donors. The need for routine liver biopsy in donor evaluation is arguable but more and more centers opt for a policy of liberal liver biopsy. Donation of the middle hepatic vein (MHV) in the right liver graft was considered unsafe but now data indicate that the outcome of donors with or without MHV donation is about equal. Right liver LDLT has been shown to improve the overall survival rate of patients with chronic liver disease, acute or acute-on-chronic liver failure and hepatocellular carcinoma waiting for liver transplantation. The outcome of LDLT is equivalent to deceased donor liver transplantation despite a smaller graft size and higher technical complexity.
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Affiliation(s)
- Sheung Tat Fan
- Department of Surgery, The University of Hong Kong, Pokfulam, Hong Kong, China.
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25
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Hilmi IA, Planinsic RM. Con: venovenous bypass should not be used in orthotopic liver transplantation. J Cardiothorac Vasc Anesth 2006; 20:744-7. [PMID: 17023301 DOI: 10.1053/j.jvca.2006.06.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Ibtesam A Hilmi
- Division of Hepatic Transplantation Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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26
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Liu CL, Fan ST, Lo CM, Wei WI, Chan SC, Yong BH, Wong J. Operative outcomes of adult-to-adult right lobe live donor liver transplantation: a comparative study with cadaveric whole-graft liver transplantation in a single center. Ann Surg 2006; 243:404-10. [PMID: 16495707 PMCID: PMC1448929 DOI: 10.1097/01.sla.0000201544.36473.a2] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate and compare the operative and survival outcomes of patients who underwent right lobe live donor liver transplantation (RLDLT) and cadaveric whole-graft liver transplant (CWLT) recipients in a single institution. SUMMARY BACKGROUND DATA Current data suggest that RLDLT has an inferior graft survival outcome when compared with CWLT. PATIENTS AND METHODS A prospective study was performed on 180 consecutive adult patients who underwent primary liver transplantation from January 2000 to February 2004. The operative and survival outcomes of RLDLT (n = 124) were compared with those of CWLT (n = 56). RESULTS Fifty-five (44%) and 16 (29%) patients were on high-urgency list in the RLDLT group and the CWLT group, respectively (P = 0.045). The preoperative Model for End-Stage Liver Disease scores were comparable in both groups. The waiting time for liver transplantation was significantly shorter in the RLDLT group. The graft weight to estimated standard liver weight ratio was significantly lower in the RLDLT group. The postoperative hospital stay and hospital mortality were comparable in the RLDLT group (1.6%) and the CWLT group (5.4%). Thirty-one (25%) patients in the RLDLT group and 3 (5%) patients in the CWLT group developed biliary stricture on follow-up (P = 0.002). At a median follow-up of 27 months, the actuarial graft and patient survival rates were 88% and 90%, respectively, in the RLDLT group, and both were 84% in the CWLT group. CONCLUSION RLDLT results in favorable operative outcomes comparable with those of CWLT. However, there is a significantly higher incidence of biliary stricture associated with RLDLT.
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Affiliation(s)
- Chi Leung Liu
- Centre for the Study of Liver, University of Hong Kong, Pokfulam, Hong Kong, China
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27
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Abdullah K, Abdeldayem H, Hali WO, Sakran A, Yassen K, Abdulkareem A. Twenty cases of adult-to-adult living-related liver transplantation: single-center experience in Saudi Arabia. Transplant Proc 2006; 37:3144-6. [PMID: 16213331 DOI: 10.1016/j.transproceed.2005.07.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The deceased donor organ shortage has forced surgeons to implement innovations, including living-related liver transplantation (LRLT). OBJECTIVE To present the first 20 cases of adult LRLT in a single center in Saudi Arabia. METHODS From November 2000 to May 2004, we performed 20 cases of LRLT. Eighteen donors were men and 2 were women. Their median age was 27 years. Seventeen of the recipients were men and 3 were women of median age 55 years. One patient received combined liver and kidney grafts. RESULTS All cases had liver cirrhosis. Seven had hepatitis C; six, hepatitis B and C; three, hepatitis B; one, alcoholic cirrhosis; one, Bylar disease, one hepatic schistosomiasis, and one cryptogenic cirrhosis. Three cases had associated hepatocellular carcinomas. There was no donor mortality. In the recipients, the overall patient and graft survival was 85%. While 10 donors presented uneventful postoperative courses, 8 experienced minor complications and 2, major complications: biliary stricture and portal vein thrombosis. Recipients complications included biliary complications (35%), acute rejection (20%), hepatitis C reactivation (20%), hepatic vein stenosis (10%), hepatic artery stenosis (5%), and hepatocellular carcinoma recurrence (5%). CONCLUSIONS LRLT has become a standard option in adults with end-stage liver failure in our center.
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Affiliation(s)
- K Abdullah
- Department of Hepatobiliary Science and Liver Transplantation, King Abdul Aziz Medical City, King Fahad National Guard Hospital, Riyadh, Saudi Arabia.
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28
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Chan SC, Fan ST. Right liver adult-to-adult live donor liver transplantation in Hong Kong. Transplant Rev (Orlando) 2006. [DOI: 10.1016/j.trre.2006.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Nadalin S, Bockhorn M, Malagó M, Valentin-Gamazo C, Frilling A, Broelsch C. Living donor liver transplantation. HPB (Oxford) 2006; 8:10-21. [PMID: 18333233 PMCID: PMC2131378 DOI: 10.1080/13651820500465626] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The introduction of living donor liver transplantation (LDLT) has been one of the most remarkable steps in the field of liver transplantation (LT). First introduced for children in 1989, its adoption for adults has followed only 10 years later. As the demand for LT continues to increase, LDLT provides life-saving therapy for many patients who would otherwise die awaiting a cadaveric organ. In recent years, LDLT has been shown to be a clinically safe addition to deceased donor liver transplantation (DDLT) and has been able to significantly extend the scarce donor pool. As long as the donor shortage continues to increase, LDLT will play an important role in the future of LT.
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Affiliation(s)
- S. Nadalin
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - M. Bockhorn
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - M. Malagó
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - C. Valentin-Gamazo
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - A. Frilling
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
| | - C.E. Broelsch
- Department of General-, Visceral- and Transplantation Surgery, University HospitalEssenGermany
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30
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Jankovic Z, Boon A, Prasad R. Fatal haemothorax following large-bore percutaneous cannulation before liver transplantation. Br J Anaesth 2005; 95:472-6. [PMID: 16085686 DOI: 10.1093/bja/aei216] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Percutaneous bypass catheters are routinely used for veno-venous bypass (VVBP) during orthotopic liver transplantation (OLT). The recognized risks include bleeding, injury of vascular and nerve structures and lymphatic leakage. We describe a case where there were difficulties during catheterization and the patient suffered a cardiac arrest on commencing VVBP. Post-mortem examination revealed the bypass catheter tip in the pleural space and a large right haemothorax. Possible mechanisms of vascular perforation and preventative measures are discussed.
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Affiliation(s)
- Z Jankovic
- Department of Anaesthesia, St James's University Hospital, UK.
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31
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Reddy K, Mallett S, Peachey T. Venovenous bypass in orthotopic liver transplantation: time for a rethink? Liver Transpl 2005; 11:741-749. [PMID: 15973707 DOI: 10.1002/lt.20482] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Kalpana Reddy
- Department of Anaesthesia, Royal Free Hospital, London, United Kingdom
| | - Susan Mallett
- Department of Anaesthesia, Royal Free Hospital, London, United Kingdom
| | - Tim Peachey
- Department of Anaesthesia, Royal Free Hospital, London, United Kingdom
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Tuttle-Newhall JE, Collins BH, Desai DM, Kuo PC, Heneghan MA. The current status of living donor liver transplantation. Curr Probl Surg 2005; 42:144-83. [PMID: 15859440 DOI: 10.1067/j.cpsurg.2004.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In response to the critical organ shortage, transplant professionals have utilized living donors in an attempt to decrease the mortality rate associated with waiting on the liver transplant list. Although the surgical techniques were first utilized clinically 15 years ago, application of LDLT has been somewhat limited by the steep learning curve associated with developing a program. Clinical success with LDLT in children was realized early in the experience and application of the techniques to the adult population has occurred more recently. Although transplant centers embark on LDLT with enthusiasm, the safety of the donor must always be at the forefront of the process. Potential donors must come to the decision to donate without pressure from members of the family or transplant team. He/she should also be assigned advocates who constantly promote the donor's best interest. Failure to adhere to strict donor evaluation protocols and standardized operative techniques could result in disastrous consequences.
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Chan SC, Liu CL, Lo CM, Fan ST. Applicability of histidine-tryptophan-ketoglutarate solution in right lobe adult-to-adult live donor liver transplantation. Liver Transpl 2004; 10:1415-21. [PMID: 15497150 DOI: 10.1002/lt.20243] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In a consecutive series of 60 right lobe adult-to-adult live donor liver transplantations (ALDLTs), safety and efficacy of the University of Wisconsin (UW) and histidine-tryptophan-ketoglutarate (HTK) solution were evaluated. The first 30 liver grafts were perfused with UW solution and the subsequent 30 by HTK solution. Donor and recipient characteristics of both groups were comparable. All liver graft implantations were performed with cross-clamping of the inferior vena cava (IVC) and without veno-venous bypass. Main outcome measures were posttransplantation liver biochemistry, prothrombin time, and recipient morbidity, as well as graft and recipient survival. There were no significant differences of the outcome measures between the 2 groups. The low potassium content of the HTK solution nonetheless offered logistic advantages. In 25 of the 30 recipients of the HTK group, portal vein anastomosis was performed with a clamp on the donor portal vein while the clamps on the IVC were already released. This shortened the period during which the IVC was being cross-clamped. HTK solution was as safe and effective as a cold storage solution as UW solution in ALDLT. Its low potassium content has advantage of earlier restoration of patency of the IVC and thus hemodynamic stability. The cost of using HTK solution was also lower.
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Affiliation(s)
- See Ching Chan
- Centre for the Study of Liver Disease and Department of Surgery, University of Hong Kong, Pokfulam, Hong Kong, China
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Lo CM, Fan ST, Liu CL, Yong BH, Wong Y, Lau GK, Lai CL, Ng IO, Wong J. Lessons learned from one hundred right lobe living donor liver transplants. Ann Surg 2004; 240:151-8. [PMID: 15213631 PMCID: PMC1356387 DOI: 10.1097/01.sla.0000129340.05238.a0] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the first 100 adult right lobe living donor liver transplants (LDLT) in a single center to determine whether the results have improved with technical modifications and better experience. SUMMARY BACKGROUND DATA Right lobe LDLT has been increasingly performed for adults with end-stage liver disease. Numerous modifications in technique have been introduced, and a learning curve is likely in view of its complexity. METHODS One hundred consecutive adult right lobe LDLTs performed between May 1996 and May 2002 were retrospectively studied by comparing the first 50 (group 1) with the last 50 cases (group 2). The median follow-up was 37 (27 to 79) months for group 1 and 15 (7 to 27) months for group 2. RESULTS The characteristics of donors and liver grafts were similar. In group 2, fewer recipients were intensive care unit (ICU)-bound or had hepatorenal syndrome before transplantation, and there was a lower disease severity as shown by a lower Child-Pugh score and Model for End-Stage Liver Disease (MELD) score. Significant improvements were found in the operation time, blood loss, ICU stay, and postoperative complication rate of the donors and in the operation time, transfusion requirements, number of reoperations, ICU stay, and hospital stay of the recipients in group 2. The hospital mortality rate of recipients was reduced from 16% to 0% (P = 0.006). Graft survival rates at 12 months and 24 months were improved from 80% and 74%, respectively, in group 1 to 100% and 96%, respectively, in group 2 (P = 0.002). After adjusting for differences in recipient risk factors (ICU-bound, hepatorenal syndrome, Child-Pugh score, and MELD score) in a multivariate Cox model, recipients in group 2 had significantly lower risk of graft loss (relative risk compared with group 1, 0.13; 95% CI, 0.03 to 0.66; P = 0.014). CONCLUSIONS There is a learning curve in adult right lobe LDLT. The results have significantly improved with technical refinement and better experience.
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Affiliation(s)
- Chung-Mau Lo
- Centre for the Study of Liver Disease, and Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
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Abstract
OBJECTIVE To evaluate the first 100 adult right lobe living donor liver transplants (LDLT) in a single center to determine whether the results have improved with technical modifications and better experience. SUMMARY BACKGROUND DATA Right lobe LDLT has been increasingly performed for adults with end-stage liver disease. Numerous modifications in technique have been introduced, and a learning curve is likely in view of its complexity. METHODS One hundred consecutive adult right lobe LDLTs performed between May 1996 and May 2002 were retrospectively studied by comparing the first 50 (group 1) with the last 50 cases (group 2). The median follow-up was 37 (27 to 79) months for group 1 and 15 (7 to 27) months for group 2. RESULTS The characteristics of donors and liver grafts were similar. In group 2, fewer recipients were intensive care unit (ICU)-bound or had hepatorenal syndrome before transplantation, and there was a lower disease severity as shown by a lower Child-Pugh score and Model for End-Stage Liver Disease (MELD) score. Significant improvements were found in the operation time, blood loss, ICU stay, and postoperative complication rate of the donors and in the operation time, transfusion requirements, number of reoperations, ICU stay, and hospital stay of the recipients in group 2. The hospital mortality rate of recipients was reduced from 16% to 0% (P = 0.006). Graft survival rates at 12 months and 24 months were improved from 80% and 74%, respectively, in group 1 to 100% and 96%, respectively, in group 2 (P = 0.002). After adjusting for differences in recipient risk factors (ICU-bound, hepatorenal syndrome, Child-Pugh score, and MELD score) in a multivariate Cox model, recipients in group 2 had significantly lower risk of graft loss (relative risk compared with group 1, 0.13; 95% CI, 0.03 to 0.66; P = 0.014). CONCLUSIONS There is a learning curve in adult right lobe LDLT. The results have significantly improved with technical refinement and better experience.
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N/A. N/A. Shijie Huaren Xiaohua Zazhi 2004; 12:434-438. [DOI: 10.11569/wcjd.v12.i2.434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
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Fan ST, Lo CM, Liu CL, Yong BH, Wong J. Determinants of hospital mortality of adult recipients of right lobe live donor liver transplantation. Ann Surg 2003; 238:864-69; discussion 869-70. [PMID: 14631223 PMCID: PMC1356168 DOI: 10.1097/01.sla.0000098618.11382.77] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To define the technical factors that might contribute to hospital mortality of recipients of right lobe live donor liver transplantation (LDLT) so as to perfect the design of the operation. SUMMARY BACKGROUND DATA Right lobe LDLT has been accepted as one of the treatments for patients with terminal hepatic failure, but the design and results of the reported series vary and the technical factors affecting hospital mortality have not been known. METHODS The data of 100 adult-to-adult right lobe LDLT performed between 1996 and 2002 were prospectively collected and retrospectively analyzed. All grafts except one contained the middle hepatic vein, which was anastomosed to the recipient middle/left hepatic vein in the first 84 recipients and directly into the inferior vena cava (with the right hepatic vein in form of venoplasty) in the subsequent 15 patients. Venovenous bypass was used routinely in the first 29 patients but not subsequently. RESULTS Eight patients died within the same hospital admission for liver transplantation. There was no hospital mortality in the last 53 recipients. Comparison of data of patients with or without hospital mortality showed that graft weight/body weight ratio, graft weight/estimated standard liver weight ratio, technical error resulting in occlusion/absence of the middle hepatic vein, use of venovenous bypass, the lowest body temperature recorded during surgery, the volume of intraoperative blood transfusion, fresh frozen plasma, and platelet infusion were significantly different between the two groups. However, the pretransplant intensive care unit status of the recipients, cold and warm ischemic time of the graft, and occurrence of biliary complications were not. By multivariate analysis, low body temperature recorded during operation, low graft weight/estimated standard liver weight ratio (</=0.35), and the middle hepatic vein occlusion were independent significant factors in determining hospital mortality. CONCLUSIONS To achieve a uniformly successful right lobe LDLT, the right lobe graft must contain a patent middle hepatic vein. With a completely patent middle hepatic vein, a graft size of >35% of the estimated standard graft weight may be sufficient for recipient survival. Hypothermia, which predisposes to coagulopathy and is enhanced by the use of venovenous bypass and massive blood, and blood product transfusion must be avoided.
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Affiliation(s)
- Sheung-Tat Fan
- Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
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Abstract
Inclusion of the middle hepatic vein (MHV) in a right lobe graft is essential to guarantee uniform venous drainage and optimum function of the graft, but end-to-end recipient-to-donor MHV anastomosis may result in outflow obstruction. To avoid outflow obstruction, we designed the venoplasty technique. From September 2000 to November 2002, 65 adult patients received right lobe live donor liver transplantation (LDLT) with grafts containing the right hepatic vein (RHV) and MHV. In the first 34 recipients, the graft RHV and MHV were anastomosed to the recipients' RHV and MHV/left hepatic vein, respectively. For the subsequent 31 recipients, the MHV was joined to the RHV at the back table to form a triangular common orifice. The septum in between the two hepatic veins was divided at the middle and sutured transversely to remove the ridge in between and to create a large opening. The common orifice was anastomosed to a matched-size triangular opening in the recipient's inferior vena cava. After reperfusion, the presence of triphasic pulsatility on spectral Doppler tracing was regarded as a sign of perfect reconstruction. In the first group, Doppler study showed little flow in the MHV in 3 patients, absent pulsatility in the MHV after portal vein reperfusion in 4 patients, and absent pulsatility in the MHV after hepatic artery reperfusion in 5 patients. In the second group, excellent triphasic pulsatility was seen in all except 1 patient (12 of 34 versus 1 of 31, P =.001). A significant increase in the peak flow velocity was seen in the MHV in the second group (median, 19.45 cm/sec versus 31.4 cm/sec, P<.001). Less time was required to complete the hepatic vein anastomoses in the second group (40 minutes versus 27 minutes, P<.001). In conclusion, hepatic venoplasty technique facilitates the implantation of the right lobe graft and guarantees outflow in the MHV.
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Affiliation(s)
- Chi-Leung Liu
- Centre for the Study of Liver Disease and Department of Surgery, The University of Hong Kong, Pokfulam, Hong Kong, China
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