Letters to the Editors 739
Surgery Volume 156, Number 3
The influence of contemporaneous revascularization on biliary complications after liver transplantation
To the Editors: I read with interest the study by Lu et al1 published recently in Surgery. The authors compared retrospectively contemporaneous portal and hepatic artery revascularization with sequential revascularization (SPA) with an interval >10 minutes during the liver transplantation (LT). In their study, SPA was followed by an increase in biliary complications (BCs; 25% vs 9%; P = .005) mainly from nonanastomotic strictures (9% vs 2%; P = .03) and tended to be more severe by the Clavien-Dindo classification. The authors concluded that the contemporaneous portal and hepatic artery revascularization protocol should be regarded as the priority for revascularization in LT. The delay in reestablishing arterial inflow in a liver perfused only by portal flow may prolong the warm ischemia time to the bile ducts and contribute to complications.2 On the basis of this premise, a progressive effect should be expected with more serious damage associated with a longer interval. We recently published our experience with a homogenous cohort of 743 LTs performed by the use of choledochocholedochostomy with T-tube, sequential reperfusion, a median cold ischemia time of 293 minutes (range, 137–887) and a median arterial ischemia time of 29 minutes (range, 9– 135)3; we observed a low rate of BCs (9%), including a 2.5% rate of stenosis, with only a 0.2% rate of nonanastomotic stenosis. Median arterial ischemia time was greater in patients with BCs 35 minutes (13 110) compared with 29 minutes (9 35) (P < .001). On multivariate analysis, only preoperative serum creatinine and arterial ischemia time >30 minutes were factors related to development of BCs. The area under the ROC curve of our model was 0.637; confidence interval 0.564– 0.710, suggesting other factors not included in our model could influence the development of BCs after LT. The retrospective study by Lu et al1 is based on two sequential nonsimultaneous cohorts what might presume a significant bias. Surprisingly, only a sequential revascularization time of >10 minutes (the definition for the SPA group) was associated with BCs, and no difference was found for the portal vein-hepatic artery interval between cases with and without BCs within the SPA group (36 ± 10 minutes vs 36 ± 7 minutes; P = .83). This cutoff point of 10 minutes for development of BCs warrants further explanation. Moreover, the incidence of vascular complications including hepatic artery thrombosis was greater in the SPA group (7% vs 3%; P = .21), and vascular complications are closely related with BCs.4 Although not statistically significant, vascular complications could have accounted for the development of BCs in the SPA group and explain the high incidence of nonanastomotic strictures in this group (9%). In summary, although simultaneous revascularization may decrease the incidence of BCs, based on our data, we maintain that this factor should not be regarded as a
priority. Decreasing the cold, warm, and arterial ischemia time or modifying technical aspects with the use of a rubber T-tube in biliary reconstruction should also be considered to achieve this goal.5 Mikel Gastaca, MD Hepatobiliary Surgery and Liver Transplantation Unit Cruces University Hospital University of the Basque Country Plaza de Cruces s/n. 48903 Bilbao, Vizcaya, Spain E-mail: [email protected]
References 1. Lu D, Xu X, Wang J, Ling Q, Xie H, Zhou L, et al. The influence of a contemporaneous portal and hepatic artery revascularization protocol on biliary complications after liver transplantation. Surgery 2014;155:190-5. 2. Adani GL, Rossetto A, Lorenzin D, Lugano M, De Anna D, Della Rocca G, et al. Sequential versus contemporaneous portal and arterial reperfusion during liver transplantation. Transplant Proc 2011;43:1107-9. 3. Gastaca M, Matarranz A, Martinez L, Mu~ noz F, Valdivieso A, Bustamante J, et al. Incidence of and risk factors for biliary complications after choledocho-choledochostomy with Ttube in orthotopic liver transplantation. A single center cohort of 743 transplants. Am J Transplant 2012;12(Suppl 3):256. 4. Dacha S, Barad A, Martin J, Levitsky J. Association of hepatic artery stenosis and biliary strictures in liver transplant recipients. Liver Transpl 2011;17:849-54. 5. Gastaca M, Valdivieso A, Ruiz P, Ventoso A, Ortiz de Urbina J. T-tube or no T-tube in cadaveric orthotopic liver transplantation: the type of tube really matters. Ann Surg, in press http://dx.doi.org/10.1016/j.surg.2014.02.019
Reply to: ‘‘The influence of contemporaneous revascularization on biliary complications after liver transplantation’’
To the Editors: We thank Dr Gastaca for his insightful comments on our article. We both believe that injuries resulting from prolonged cold, warm, and arterial ischemic time should be one of the major concerns for liver transplantation. In the study by Gastaca et al,1 the incidence of biliary complications was 9% in a cohort of 743 transplants with the use of a T-tube1; however, the biliary complications were excluded from his study when they occurred in conjunction with hepatic artery thrombosis, which is different from our study. Therefore, the data from the two studies was not comparable, not to mention the intrinsic differences between Western and Chinese patient populations. What is interesting in the study by Gastaca et al is that prolonged arterial ischemic time can result in a greater incidence of biliary complications within the SPA (sequential portal and hepatic arterial revascularization) cohort. Their study provided the evidence that the arterial ischemic time is detrimental to the biliary system and should be limited whenever possible. To achieve this goal,
740 Letters to the Editors
our center has been adopting the contemporaneous portal and hepatic arterial revascularization (CPA) protocol since 2008, and the arterial ischemic time was eliminated exclusively. As for the question Dr Gastaca raised regarding the cut-off point of arterial ischemic time, we do not think there was a bias. The arterial ischemic time was beyond 10 minutes in all the transplants with the SPA protocol. In a few cases, we planned to perform the CPA protocol, but the arterial revascularization was delayed slightly because of accidental bleeding, which resulted in an arterial ischemic time of 2–4 minutes.2 These patients were excluded from our study to avoid bias. Three additional points might help when one is making the choice between the SPA and CPA protocols: (1) For some relatively inexperienced surgical teams, arterial anastomosis after portal reperfusion (under the SPA protocol) might increase the difficulty because of bleeding in the surgical field, which will increase the arterial ischemic time. (2) The CPA protocol only increased the cold ischemic time by an average of 3% compared to the SPA protocol and caused no additional injuries to the whole liver graft in our study. In the Cochrane study, Gurusamy et al also concluded that the CPA protocol does not impair posttransplant liver function compared to the SPA protocol.3 (3) Portal reperfusion before hepatic arterial reperfusion could result in the retrograde flow to the hepatic artery as well as the hepatic arterial thrombosis,4 which impairs perfusion of the biliary system.5 Therefore, the SPA protocol might increase posttransplant biliary injury. The use of a T-tube is controversial. Although a Ttube might decrease the incidence of biliary stricture in liver transplantation,6 various studies showed increased risk of bile leak.7 In the study by Gastaca et al, bile leak and other T-tube-related biliary complications accounted for as much as 74% of all the biliary complications; our center has been one of the earliest centers abandoning the use of T tubes in liver transplantations, and bile leak accounted for only 16% of all biliary complications in our study. No good evidence favors the use of a T-tube in liver transplantation. Di Lu, MD* Xiao Xu, PhD* Shusen Zheng, MD, PhD, FACS Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital Zhejiang University School of Medicine Hangzhou, 310003, China E-mail: [email protected] * Contributed equally to this work.
References 1. Gastaca M, Matarranz A, Martinez L, Mu~ noz F, Valdivieso A, Bustamante J, et al. Incidence of and risk factors for biliary complications after choledocho-choledochostomy with Ttube in orthotopic liver transplantation. A single center cohort of 743 transplants. Am J Transplant 2012;12(Suppl 3):256.
Surgery September 2014
2. Lu D, Xu X, Wang J, Ling Q, Xie H, Zhou L, et al. The influence of a contemporaneous portal and hepatic artery revascularization protocol on biliary complications after liver transplantation. Surgery 2014;155:190-5. 3. Gurusamy KS, Naik P, Abu-Amara M, Fuller B, Davidson BR. Techniques of flushing and reperfusion for liver transplantation. Cochrane Database Syst Rev 2012:CD007512. 4. Brockmann JG, August C, Wolters HH, Homme R, Palmes D, Baba H, et al. Sequence of reperfusion influences ischemia/reperfusion injury and primary graft function following porcine liver transplantation. Liver Transpl 2005; 11:1214-22. 5. Guichelaar MM, Benson JT, Malinchoc M, Krom RA, Wiesner RH, Charlton MR. Risk factors for and clinical course of nonanastomotic biliary strictures after liver transplantation. Am J Transplant 2003;3:885-90. 6. Riediger C, Muller MW, Michalski CW, Huser N, Schuster T, Kleeff J, et al. T-Tube or no T-tube in the reconstruction of the biliary tract during orthotopic liver transplantation: systematic review and meta-analysis. Liver Transpl 2010;16: 705-17. 7. Seehofer D, Eurich D, Veltzke-Schlieker W, Neuhaus P. Biliary complications after liver transplantation: old problems and new challenges. Am J Transplant 2013; 13:253-65. http://dx.doi.org/10.1016/j.surg.2014.04.037
Preoperative symptoms and inguinal herniorrhaphy
To the Editors: I read with interest the report by Magnusson et al1 regarding improvement in Short Form-36 scores after inguinal hernia repair. Although not cited by the authors, their report essentially duplicates and corroborates, in greater detail and with 3 times as many patients, the earlier report on the same topic in which we demonstrated the feasibility of using the Short Form-36 for outcomes measurement in inguinal hernia repair.2 Our findings were virtually identical to the results of Magnusson et al: 69% (vs 64%) of patients reported some form of pain, commonly described as a dull ache or pressure sensation. Patients with hernia had lesser scores only in physical function and physical role limitation. Postoperatively, these scores improved to normal or greater. Although Magnusson et al focus on the symptom of ‘‘pain,’’ they did not make any determination preoperatively of whether the pain being experienced by the patient was actually hernia-related or not. This focus is an important consideration because, in my experience, many if not most patients who present with postherniorrhaphy pain had the same or similar preoperative pain (often with no clinically evident hernia) for which they underwent hernia repair under the assumption that it was hernia-related. I see many patients with groin pain that in its character, location, duration, and other characteristics is clearly not related to inguinal hernia, whether a hernia is clinically evident or not. If we are to make progress in finding the reasons for pain after hernia repair, I think we must look more carefully at preoperative pain characteristics.
Surgery Volume 156, Number 3
The influence of contemporaneous revascularization on biliary complications after liver transplantation
To the Editors: I read with interest the study by Lu et al1 published recently in Surgery. The authors compared retrospectively contemporaneous portal and hepatic artery revascularization with sequential revascularization (SPA) with an interval >10 minutes during the liver transplantation (LT). In their study, SPA was followed by an increase in biliary complications (BCs; 25% vs 9%; P = .005) mainly from nonanastomotic strictures (9% vs 2%; P = .03) and tended to be more severe by the Clavien-Dindo classification. The authors concluded that the contemporaneous portal and hepatic artery revascularization protocol should be regarded as the priority for revascularization in LT. The delay in reestablishing arterial inflow in a liver perfused only by portal flow may prolong the warm ischemia time to the bile ducts and contribute to complications.2 On the basis of this premise, a progressive effect should be expected with more serious damage associated with a longer interval. We recently published our experience with a homogenous cohort of 743 LTs performed by the use of choledochocholedochostomy with T-tube, sequential reperfusion, a median cold ischemia time of 293 minutes (range, 137–887) and a median arterial ischemia time of 29 minutes (range, 9– 135)3; we observed a low rate of BCs (9%), including a 2.5% rate of stenosis, with only a 0.2% rate of nonanastomotic stenosis. Median arterial ischemia time was greater in patients with BCs 35 minutes (13 110) compared with 29 minutes (9 35) (P < .001). On multivariate analysis, only preoperative serum creatinine and arterial ischemia time >30 minutes were factors related to development of BCs. The area under the ROC curve of our model was 0.637; confidence interval 0.564– 0.710, suggesting other factors not included in our model could influence the development of BCs after LT. The retrospective study by Lu et al1 is based on two sequential nonsimultaneous cohorts what might presume a significant bias. Surprisingly, only a sequential revascularization time of >10 minutes (the definition for the SPA group) was associated with BCs, and no difference was found for the portal vein-hepatic artery interval between cases with and without BCs within the SPA group (36 ± 10 minutes vs 36 ± 7 minutes; P = .83). This cutoff point of 10 minutes for development of BCs warrants further explanation. Moreover, the incidence of vascular complications including hepatic artery thrombosis was greater in the SPA group (7% vs 3%; P = .21), and vascular complications are closely related with BCs.4 Although not statistically significant, vascular complications could have accounted for the development of BCs in the SPA group and explain the high incidence of nonanastomotic strictures in this group (9%). In summary, although simultaneous revascularization may decrease the incidence of BCs, based on our data, we maintain that this factor should not be regarded as a
priority. Decreasing the cold, warm, and arterial ischemia time or modifying technical aspects with the use of a rubber T-tube in biliary reconstruction should also be considered to achieve this goal.5 Mikel Gastaca, MD Hepatobiliary Surgery and Liver Transplantation Unit Cruces University Hospital University of the Basque Country Plaza de Cruces s/n. 48903 Bilbao, Vizcaya, Spain E-mail: [email protected]
References 1. Lu D, Xu X, Wang J, Ling Q, Xie H, Zhou L, et al. The influence of a contemporaneous portal and hepatic artery revascularization protocol on biliary complications after liver transplantation. Surgery 2014;155:190-5. 2. Adani GL, Rossetto A, Lorenzin D, Lugano M, De Anna D, Della Rocca G, et al. Sequential versus contemporaneous portal and arterial reperfusion during liver transplantation. Transplant Proc 2011;43:1107-9. 3. Gastaca M, Matarranz A, Martinez L, Mu~ noz F, Valdivieso A, Bustamante J, et al. Incidence of and risk factors for biliary complications after choledocho-choledochostomy with Ttube in orthotopic liver transplantation. A single center cohort of 743 transplants. Am J Transplant 2012;12(Suppl 3):256. 4. Dacha S, Barad A, Martin J, Levitsky J. Association of hepatic artery stenosis and biliary strictures in liver transplant recipients. Liver Transpl 2011;17:849-54. 5. Gastaca M, Valdivieso A, Ruiz P, Ventoso A, Ortiz de Urbina J. T-tube or no T-tube in cadaveric orthotopic liver transplantation: the type of tube really matters. Ann Surg, in press http://dx.doi.org/10.1016/j.surg.2014.02.019
Reply to: ‘‘The influence of contemporaneous revascularization on biliary complications after liver transplantation’’
To the Editors: We thank Dr Gastaca for his insightful comments on our article. We both believe that injuries resulting from prolonged cold, warm, and arterial ischemic time should be one of the major concerns for liver transplantation. In the study by Gastaca et al,1 the incidence of biliary complications was 9% in a cohort of 743 transplants with the use of a T-tube1; however, the biliary complications were excluded from his study when they occurred in conjunction with hepatic artery thrombosis, which is different from our study. Therefore, the data from the two studies was not comparable, not to mention the intrinsic differences between Western and Chinese patient populations. What is interesting in the study by Gastaca et al is that prolonged arterial ischemic time can result in a greater incidence of biliary complications within the SPA (sequential portal and hepatic arterial revascularization) cohort. Their study provided the evidence that the arterial ischemic time is detrimental to the biliary system and should be limited whenever possible. To achieve this goal,
740 Letters to the Editors
our center has been adopting the contemporaneous portal and hepatic arterial revascularization (CPA) protocol since 2008, and the arterial ischemic time was eliminated exclusively. As for the question Dr Gastaca raised regarding the cut-off point of arterial ischemic time, we do not think there was a bias. The arterial ischemic time was beyond 10 minutes in all the transplants with the SPA protocol. In a few cases, we planned to perform the CPA protocol, but the arterial revascularization was delayed slightly because of accidental bleeding, which resulted in an arterial ischemic time of 2–4 minutes.2 These patients were excluded from our study to avoid bias. Three additional points might help when one is making the choice between the SPA and CPA protocols: (1) For some relatively inexperienced surgical teams, arterial anastomosis after portal reperfusion (under the SPA protocol) might increase the difficulty because of bleeding in the surgical field, which will increase the arterial ischemic time. (2) The CPA protocol only increased the cold ischemic time by an average of 3% compared to the SPA protocol and caused no additional injuries to the whole liver graft in our study. In the Cochrane study, Gurusamy et al also concluded that the CPA protocol does not impair posttransplant liver function compared to the SPA protocol.3 (3) Portal reperfusion before hepatic arterial reperfusion could result in the retrograde flow to the hepatic artery as well as the hepatic arterial thrombosis,4 which impairs perfusion of the biliary system.5 Therefore, the SPA protocol might increase posttransplant biliary injury. The use of a T-tube is controversial. Although a Ttube might decrease the incidence of biliary stricture in liver transplantation,6 various studies showed increased risk of bile leak.7 In the study by Gastaca et al, bile leak and other T-tube-related biliary complications accounted for as much as 74% of all the biliary complications; our center has been one of the earliest centers abandoning the use of T tubes in liver transplantations, and bile leak accounted for only 16% of all biliary complications in our study. No good evidence favors the use of a T-tube in liver transplantation. Di Lu, MD* Xiao Xu, PhD* Shusen Zheng, MD, PhD, FACS Division of Hepatobiliary and Pancreatic Surgery Department of Surgery First Affiliated Hospital Zhejiang University School of Medicine Hangzhou, 310003, China E-mail: [email protected] * Contributed equally to this work.
References 1. Gastaca M, Matarranz A, Martinez L, Mu~ noz F, Valdivieso A, Bustamante J, et al. Incidence of and risk factors for biliary complications after choledocho-choledochostomy with Ttube in orthotopic liver transplantation. A single center cohort of 743 transplants. Am J Transplant 2012;12(Suppl 3):256.
Surgery September 2014
2. Lu D, Xu X, Wang J, Ling Q, Xie H, Zhou L, et al. The influence of a contemporaneous portal and hepatic artery revascularization protocol on biliary complications after liver transplantation. Surgery 2014;155:190-5. 3. Gurusamy KS, Naik P, Abu-Amara M, Fuller B, Davidson BR. Techniques of flushing and reperfusion for liver transplantation. Cochrane Database Syst Rev 2012:CD007512. 4. Brockmann JG, August C, Wolters HH, Homme R, Palmes D, Baba H, et al. Sequence of reperfusion influences ischemia/reperfusion injury and primary graft function following porcine liver transplantation. Liver Transpl 2005; 11:1214-22. 5. Guichelaar MM, Benson JT, Malinchoc M, Krom RA, Wiesner RH, Charlton MR. Risk factors for and clinical course of nonanastomotic biliary strictures after liver transplantation. Am J Transplant 2003;3:885-90. 6. Riediger C, Muller MW, Michalski CW, Huser N, Schuster T, Kleeff J, et al. T-Tube or no T-tube in the reconstruction of the biliary tract during orthotopic liver transplantation: systematic review and meta-analysis. Liver Transpl 2010;16: 705-17. 7. Seehofer D, Eurich D, Veltzke-Schlieker W, Neuhaus P. Biliary complications after liver transplantation: old problems and new challenges. Am J Transplant 2013; 13:253-65. http://dx.doi.org/10.1016/j.surg.2014.04.037
Preoperative symptoms and inguinal herniorrhaphy
To the Editors: I read with interest the report by Magnusson et al1 regarding improvement in Short Form-36 scores after inguinal hernia repair. Although not cited by the authors, their report essentially duplicates and corroborates, in greater detail and with 3 times as many patients, the earlier report on the same topic in which we demonstrated the feasibility of using the Short Form-36 for outcomes measurement in inguinal hernia repair.2 Our findings were virtually identical to the results of Magnusson et al: 69% (vs 64%) of patients reported some form of pain, commonly described as a dull ache or pressure sensation. Patients with hernia had lesser scores only in physical function and physical role limitation. Postoperatively, these scores improved to normal or greater. Although Magnusson et al focus on the symptom of ‘‘pain,’’ they did not make any determination preoperatively of whether the pain being experienced by the patient was actually hernia-related or not. This focus is an important consideration because, in my experience, many if not most patients who present with postherniorrhaphy pain had the same or similar preoperative pain (often with no clinically evident hernia) for which they underwent hernia repair under the assumption that it was hernia-related. I see many patients with groin pain that in its character, location, duration, and other characteristics is clearly not related to inguinal hernia, whether a hernia is clinically evident or not. If we are to make progress in finding the reasons for pain after hernia repair, I think we must look more carefully at preoperative pain characteristics.
