LETTER TO Liver Transplantation and Portal Vein Thrombosis: An Unfinished Saga To the Editor: e have read with great interest the article by Dr Hibi et al,1 published in December 2013 on the Annals of Surgery Web site, titled ‘‘When and Why Portal Vein Thrombosis Matters in Liver Transplantation: A Critical Audit of 174 Cases.’’ Our comments specifically focus on the subset of patients with diffuse portal vein thrombosis (PVT) [the so-called stage 4 PVT in the Yerdel classification].2 Revascularization of the portal vein graft is mandatory to ensure graft and patient survival after liver transplantation. After more than 40 years, liver transplantation of patients with stage 4 PVT remains a formidable technical challenge. Various techniques have been described to overcome this problem: multivisceral transplantation, renoportal anastomosis, cavoportal hemitransposition, and portal vein arterialization (PVA). Three prerequisites should be fulfilled to optimize liver transplantation in patients with stage 4 PVT: (1) selecting optimal donor liver graft; (2) restoring adequate portal inflow to the graft; and (3) ensuring splanchnic venous drainage to cure prehepatic portal hypertension. In theory, multivisceral transplantation is the procedure of choice: liver replacement cures the underlying liver disease, whereas the healthy portal system provided by the intestinal graft cures the prehepatic portal hypertension.3 In practice, multivisceral transplantation remains a complex procedure and the high rate of small bowel rejection is a major limiting factor.4 Vianna and his group5 from Indianapolis, IN, have chosen this option. They reported patient and graft survival rates exceeding 70% at 5 years in 25 recipients with stage 4 PVT after multivisceral transplantation. Nevertheless, because of long waiting lists, restrictions of organ allocation policies, and the intrinsic risks of small bowel transplantation, some transplant centers have favored other alternatives to reestablish venous flow to the portal vein. These so-called nonanatomic surgical techniques use the caval (renoportal anastomosis and cavoportal

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Disclosure: The authors declare no conflicts of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000000639

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EDITOR

hemitransposition) or arterial (PVA) inflows to the graft portal vein. The choice between renoportal anastomosis and cavoportal hemitransposition remains debated. Although these nonanatomic reconstructions provide satisfactory portal flow to the liver graft, their effect of simultaneous portal decompression depends on the degree of development of shunts (surgical or spontaneous) between the splanchnic venous and caval circulations. In addition, the prevention of postoperative complications of remnant portal hypertension may include pretransplant intensive program of varice ligation, pertransplant gastric devascularization, and even splenectomy. We reported a survival rate of 60% at 5 years in 20 recipients with caval inflow to the graft (17 had renoportal anastomosis and 3 had cavoportal hemitransposition).6 These figures are satisfactory, considering the bad outcome in such patients with no transplant. Like the authors, we agree that portal hypertension is the main problem in the postoperative period after nonanatomic portal reconstruction. Finally, in the Miami series, PVA was performed in one patient with stage 4 PVT to increase portal inflow into the transplanted liver. This technique of PVA (an anastomosis between the arterial circulation and the splanchnic venous system) aims to maintain portal vein patency when the portal flow is not satisfactory upon graft revascularization. However, a high incidence of severe complications of portal hypertension has been reported after PVA even in patients without preexisting portal hypertension. We have performed PVA only to restore arterial inflow to a totally ‘‘dearterialized’’ liver when no other form of arterial reconstruction is possible. We showed recently7 that 44% of patients had some form of portal hypertension –related complications after PVA: significant bleeding (either intraabdominal or variceal) and massive ascites occurred in 19% and 25% of patients, respectively. In summary, the authors, to be commended for their study, illustrate how the complex surgical management of patients with diffuse PVT in the setting of liver transplantation is still open to debate and evolution. In our opinion, the theoretically optimal option of multivisceral transplantation is offset by the intrinsic risks of intestinal transplantation. PVA should remain a last resort. Renoportal and cavoportal anastomoses provide more reasonable alternatives with good long-term results. The versatility of technical options to transplant patients with stage 4 PVT emphasizes if needed that liver transplantation still remains an ‘‘unfinished product.’’

Chetana Lim, MD Chady Salloum, MD Philippe Compagnon, MD, PhD Alexis Laurent, MD, PhD Daniel Azoulay, MD, PhD Department of HPB Surgery and Liver Transplantation Henri Mondor Hospital Assistance Publique des Hoˆpitaux de Paris (AP-HP) Faculte´ de Me´decine Universite´ Paris-Est Cre´teil, France [email protected]

REFERENCES 1. Hibi T, Nishida S, Levi DM, et al. When and why portal vein thrombosis matters in liver transplantation: a critical audit of 174 cases. Ann Surg. 2014;259:760–766. 2. Yerdel MA, Gunson B, Mirza D, et al. Portal vein thrombosis in adults undergoing liver transplantation: risk factors, screening, management, and outcome. Transplantation. 2000;69:1873–1881. 3. Lim C, Bhangui P, Salloum C, et al. Multivisceral transplantation for diffuse portomesenteric thrombosis. Ann Surg. 2015;261:e48. 4. Fujishiro J, Pech TC, Finger TF, et al. Influence of immunosuppression on alloresponse, inflammation and contractile function of graft after intestinal transplantation. Am J Transplant. 2010;10:1545–1555. 5. Vianna RM, Mangus RS, Kubal C, et al. Multivisceral transplantation for diffuse portomesenteric thrombosis. Ann Surg. 2012;255:1144– 1150. 6. Bhangui P, Lim C, Salloum C, et al. Caval inflow to the graft for liver transplantation in patients with diffuse portal vein thrombosis: a 12-year experience. Ann Surg. 2011;254:1008–1016. 7. Bhangui P, Salloum C, Lim C, et al. Portal vein arterialization: a salvage procedure for a totally de-arterialized liver. The Paul Brousse Hospital experience. HPB (Oxford). 2014;16:723–738.

Reply: e agree that there is a trade-off between the theoretical advantage of multivisceral transplantation for diffuse portal vein thrombosis (Yerdel grade 4)1 and the potential complications of small bowel transplantation that can be fatal. Our early encouraging results with multivisceral transplantation and those of Vianna et al2 should be applicable to a small subset of patients who have advanced end-stage liver disease combined with severe bowel dysfunction or refractory gastrointestinal bleeding due to longstanding portal vein thrombosis and who are able to survive a multivisceral transplantation. For all other patients, the nonphysiological portal vein reconstructions (cavoportal hemitransposition and renoportal anastomosis) as practiced

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Disclosure: The authors declare no conflicts of interest. DOI: 10.1097/SLA.0000000000000638

Annals of Surgery  Volume 262, Number 6, December 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Liver Transplantation and Portal Vein Thrombosis: An Unfinished Saga.

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