CORRESPONDENCE
Portomesenteric Shunt for Liver Transplantation and Complete Portal Vein Thrombosis e read the article by Rodrı´guezCastro et al. (1) published in the December 2012 issue of Transplantation entitled ‘‘Management of Nonneoplastic Portal Vein Thrombosis in the Setting of Liver Transplantation: A Systemic Review’’ with great interest. We totally agree that the subject is very interesting and so are the authors’ results, but we would like to describe in this letter our results in a surgical technique that can overcome this problem but which is underestimated and not well known for liver transplant (LT) surgeons. LT in the setting of cirrhosis and nonneoplastic portomesenteric thrombosis (NPMT) is controversial and even contraindicated in many transplant centers, especially in patients with diffuse thrombosis. NPMT is frequent (8%), complicates surgery,
W
significantly increases postoperative mortality and morbidity, and is a major risk of long-term portal vein thrombosis (PVT) (1Y3). Although NPMT has been considered a contraindication to LT, many alternative surgical techniques have been developed to sustain portal flow to the liver graft. These alternative surgical techniques depend mainly on the grade of NPMT and probably the experience of the surgical team. Four types of NPMT have been described including partial PVT (grade I), complete PVT (grade II), partial superior mesenteric vein (SMV) thrombosis (grade III), and complete SMV thrombosis (type IV) (2). In cases of LT and NPMT, graft portal flow can be established by anatomical (portal vein thrombectomy, portomesenteric shunts, or combined small
bowel and LT) or nonanatomical (renoportal shunts or portocaval hemitransposition) routes (4, 5). Nonanatomical shunts mainly depend on the coexistence of abnormally developed venous shunts between the splanchnic and caval circulations. These shunts are inconstant even in patients with severe portal hypertension, which can explain the high morbidity and mortality rate of LT using nonanatomical shunts (6). Although anatomical (especially portomesenteric) shunts have the advantage of directly perfusing the liver graft by the splanchnic blood independent of the presence of abnormal venous shunts, these shunts are technically difficult and are usually contraindicated in grade IV thrombosis.
FIGURE 1. Computed tomography scan (A) in a patient with alcoholic cirrhosis showing grade II PVT with patent SMV. Harvested iliac vein graft (B) was anastomosed as end-side on the SMV, which was clamped laterally (C). The venous shunt (D) is passed anteriorly to the pancreatic neck (white arrow). Postoperative computed tomography scan showing the patent venous shunt (black arrow) implanted laterally on the SMV (yellow arrow) at its origin (E) and in the liver graft (F).
e68
www.transplantjournal.com
Transplantation
& Volume 96, Number 10, November 27, 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Correspondence
* 2013 Lippincott Williams & Wilkins
In patients with cirrhosis, dissection of the SMV can be challenging due to severe portal hypertension and the inflammatory mesenteric root, especially in patients with history of recurrent ascites or encapsulated peritonitis (inflammatory adhesions) with the risk of uncontrolled bleeding. This can explain why this surgical modality has rarely been described or performed, although it might be the most effective choice in these cases. In our opinion, dissection should be performed by a surgeon who has experience in both LT and pancreatic surgery. We illustrate our surgical technique in a 57-year-old male patient who had LT for Child C alcoholic cirrhosis and grade II PVT. After total hepatectomy, a good portal flow cannot be obtained by thrombectomy. We prepare the portomesenteric shunt as follows (Fig. 1). Dissection begins by right coloepiploic liberation with right colonic angle full down mobilization. Although identifying the anatomical structures can be difficult, our surgical landmarks are the inferior border of the pancreas and the right gastroepiploic vein (RGEV) coupled with Doppler ultrasound. The inferior pancreatic edge is freed at the neck to expose the anterior aspect of the SMV. An attempt is made to mobilize the right mesocolon from the pancreatic head to obtain access to the SMV below the insertion of the RGEV. Some small colonic pedicles may be sacrificed. When 2 to 3 cm of the anterior SMV are exposed, the lateral borders are freed and care is taken of the small collateral veins. Complete control of the SMV is not needed and there is a risk
of uncontrollable bleeding if the posterior collaterals veins are injured. Lateral clamping centered on the insertion of the RGEV is usually enough to obtain a 1cm opening. In some patients, the RGEV is dilated due to portal hypertension and can be used to enlarge and facilitate anastomosis. The donor iliac vein is used to perform end-side anastomosis on the SMV (5 or 6/0 monofilament) and then passed anteriorly to the pancreatic neck for end-end anastomosis on the portal vein graft. Kinking with the inferior margin of the pancreas should be avoided. The liver graft should only be transplanted when good portal flow has been obtained; otherwise, another surgical alternative should be searched. Patients receive anti coagulation therapy for a few weeks. Since 2010, portomesenteric shunts were planned in 11 patients with PVT grades II and III and the technique was converted to renoportal shunt in one case due to difficulty controlling the SMV and bleeding. Three patients died due to severe intraoperative bleeding (n=1), arterial aneurysm rupture (n=1), and multiorgan failure (n=1) and none from impaired portal flow. Two patients were retrans planted due to hepatic artery thrombosis and primary graft nonfunction.
2
REFERENCES 1.
2.
3. 4.
1
Department of HBP Surgery and Liver Transplantation, Beaujon Hospital Clichy, France
Department of Hepatology Beaujon Hospital Clichy, France
The authors declare no funding or conflicts of interest. Address correspondence to: Safi Dokmak, M.D., Department of HBP Surgery and Liver Transplantation, Beaujon Hospital, 100 Bd du Ge´ne´ral Leclerc, 92110 Clichy, France. E-mail: [email protected] S.D., B.A., and J.B. participated in the research design, writing of the article, and performance of the research. F.D., C.F., and F.D. participated in the research design and performance of the research. Received 7 August 2013. Accepted 30 August 2013. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0041-1337/13/9610-e68 DOI: 10.1097/01.TP.0000435700.76890.65
1
Safi Dokmak Be´atrice Aussilhou1 Federica Donde´ro1 Claire Francoz2 Fran0ois Durand2 Jacques Belghiti1
e69
5. 6.
Rodrı´guez-CastroKI,Porte RJ, Nadal E, et al. Management of nonneoplastic portal vein thrombosis in the setting of liver transplantation: a systematic review. Transplantation 2012; 94: 1145. 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. Francoz C, Valla D, Durand F. Portal vein thrombosis, cirrhosis, and liver transplantation. J Hepatol 2012; 57: 203. 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. Vianna RM, Mangus RS, Kubal C, et al. Multivisceral transplantation for diffuse portomesenteric thrombosis. Ann Surg 2012; 255: 1144. Selvaggi G, Weppler D, Nishida S, et al. Ten-year experience in porto-caval hemitransposition for liver transplantation in the presence of portal vein thrombosis. Am J Transplant 2007; 7: 454.
Cavoportal Hemitransposition Associated to Portoportal Anastomosis for Liver Transplant in Portomesenteric Thrombosis e read with interest the correspondence by Dokmak et al. (1), which makes reference to the recently published systematic review (2); both papers underline how the fascinating issue of nonneoplastic portomesenteric thrombosis (NPMT) in the setting of liver transplantation is still open to refinements and evolution. In particular, two relevant and deeply intertwined issues emerge, which merit clarification. Foremost, NPMT
W
should probably no longer be considered a contraindication for liver transplantation. Secondly, there is still the need for a better standardization of technical solutions to the multiple and variable anatomoclinical situations that can be encountered. Increasing technical experience in portal thrombectomy as well as in finding solutions to reperfuse the graft in the presence of a complete thrombosis of the portomesenteric axis (1, 3, 4) have
reduced the prevalence of posttransplantation mortality to less than 20% in most experiences (5Y7). Based on this, a patient should not be refused liver transplantation, independently from the grade of thrombosis, as long as an acceptable surgical risk dictated by comorbidities is present and an adequate transplant benefit is expected. Indeed, this is the case in most liver transplant candidates with NPMT, who present a high mortality risk in the absence of an
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Portomesenteric Shunt for Liver Transplantation and Complete Portal Vein Thrombosis e read the article by Rodrı´guezCastro et al. (1) published in the December 2012 issue of Transplantation entitled ‘‘Management of Nonneoplastic Portal Vein Thrombosis in the Setting of Liver Transplantation: A Systemic Review’’ with great interest. We totally agree that the subject is very interesting and so are the authors’ results, but we would like to describe in this letter our results in a surgical technique that can overcome this problem but which is underestimated and not well known for liver transplant (LT) surgeons. LT in the setting of cirrhosis and nonneoplastic portomesenteric thrombosis (NPMT) is controversial and even contraindicated in many transplant centers, especially in patients with diffuse thrombosis. NPMT is frequent (8%), complicates surgery,
W
significantly increases postoperative mortality and morbidity, and is a major risk of long-term portal vein thrombosis (PVT) (1Y3). Although NPMT has been considered a contraindication to LT, many alternative surgical techniques have been developed to sustain portal flow to the liver graft. These alternative surgical techniques depend mainly on the grade of NPMT and probably the experience of the surgical team. Four types of NPMT have been described including partial PVT (grade I), complete PVT (grade II), partial superior mesenteric vein (SMV) thrombosis (grade III), and complete SMV thrombosis (type IV) (2). In cases of LT and NPMT, graft portal flow can be established by anatomical (portal vein thrombectomy, portomesenteric shunts, or combined small
bowel and LT) or nonanatomical (renoportal shunts or portocaval hemitransposition) routes (4, 5). Nonanatomical shunts mainly depend on the coexistence of abnormally developed venous shunts between the splanchnic and caval circulations. These shunts are inconstant even in patients with severe portal hypertension, which can explain the high morbidity and mortality rate of LT using nonanatomical shunts (6). Although anatomical (especially portomesenteric) shunts have the advantage of directly perfusing the liver graft by the splanchnic blood independent of the presence of abnormal venous shunts, these shunts are technically difficult and are usually contraindicated in grade IV thrombosis.
FIGURE 1. Computed tomography scan (A) in a patient with alcoholic cirrhosis showing grade II PVT with patent SMV. Harvested iliac vein graft (B) was anastomosed as end-side on the SMV, which was clamped laterally (C). The venous shunt (D) is passed anteriorly to the pancreatic neck (white arrow). Postoperative computed tomography scan showing the patent venous shunt (black arrow) implanted laterally on the SMV (yellow arrow) at its origin (E) and in the liver graft (F).
e68
www.transplantjournal.com
Transplantation
& Volume 96, Number 10, November 27, 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Correspondence
* 2013 Lippincott Williams & Wilkins
In patients with cirrhosis, dissection of the SMV can be challenging due to severe portal hypertension and the inflammatory mesenteric root, especially in patients with history of recurrent ascites or encapsulated peritonitis (inflammatory adhesions) with the risk of uncontrolled bleeding. This can explain why this surgical modality has rarely been described or performed, although it might be the most effective choice in these cases. In our opinion, dissection should be performed by a surgeon who has experience in both LT and pancreatic surgery. We illustrate our surgical technique in a 57-year-old male patient who had LT for Child C alcoholic cirrhosis and grade II PVT. After total hepatectomy, a good portal flow cannot be obtained by thrombectomy. We prepare the portomesenteric shunt as follows (Fig. 1). Dissection begins by right coloepiploic liberation with right colonic angle full down mobilization. Although identifying the anatomical structures can be difficult, our surgical landmarks are the inferior border of the pancreas and the right gastroepiploic vein (RGEV) coupled with Doppler ultrasound. The inferior pancreatic edge is freed at the neck to expose the anterior aspect of the SMV. An attempt is made to mobilize the right mesocolon from the pancreatic head to obtain access to the SMV below the insertion of the RGEV. Some small colonic pedicles may be sacrificed. When 2 to 3 cm of the anterior SMV are exposed, the lateral borders are freed and care is taken of the small collateral veins. Complete control of the SMV is not needed and there is a risk
of uncontrollable bleeding if the posterior collaterals veins are injured. Lateral clamping centered on the insertion of the RGEV is usually enough to obtain a 1cm opening. In some patients, the RGEV is dilated due to portal hypertension and can be used to enlarge and facilitate anastomosis. The donor iliac vein is used to perform end-side anastomosis on the SMV (5 or 6/0 monofilament) and then passed anteriorly to the pancreatic neck for end-end anastomosis on the portal vein graft. Kinking with the inferior margin of the pancreas should be avoided. The liver graft should only be transplanted when good portal flow has been obtained; otherwise, another surgical alternative should be searched. Patients receive anti coagulation therapy for a few weeks. Since 2010, portomesenteric shunts were planned in 11 patients with PVT grades II and III and the technique was converted to renoportal shunt in one case due to difficulty controlling the SMV and bleeding. Three patients died due to severe intraoperative bleeding (n=1), arterial aneurysm rupture (n=1), and multiorgan failure (n=1) and none from impaired portal flow. Two patients were retrans planted due to hepatic artery thrombosis and primary graft nonfunction.
2
REFERENCES 1.
2.
3. 4.
1
Department of HBP Surgery and Liver Transplantation, Beaujon Hospital Clichy, France
Department of Hepatology Beaujon Hospital Clichy, France
The authors declare no funding or conflicts of interest. Address correspondence to: Safi Dokmak, M.D., Department of HBP Surgery and Liver Transplantation, Beaujon Hospital, 100 Bd du Ge´ne´ral Leclerc, 92110 Clichy, France. E-mail: [email protected] S.D., B.A., and J.B. participated in the research design, writing of the article, and performance of the research. F.D., C.F., and F.D. participated in the research design and performance of the research. Received 7 August 2013. Accepted 30 August 2013. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0041-1337/13/9610-e68 DOI: 10.1097/01.TP.0000435700.76890.65
1
Safi Dokmak Be´atrice Aussilhou1 Federica Donde´ro1 Claire Francoz2 Fran0ois Durand2 Jacques Belghiti1
e69
5. 6.
Rodrı´guez-CastroKI,Porte RJ, Nadal E, et al. Management of nonneoplastic portal vein thrombosis in the setting of liver transplantation: a systematic review. Transplantation 2012; 94: 1145. 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. Francoz C, Valla D, Durand F. Portal vein thrombosis, cirrhosis, and liver transplantation. J Hepatol 2012; 57: 203. 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. Vianna RM, Mangus RS, Kubal C, et al. Multivisceral transplantation for diffuse portomesenteric thrombosis. Ann Surg 2012; 255: 1144. Selvaggi G, Weppler D, Nishida S, et al. Ten-year experience in porto-caval hemitransposition for liver transplantation in the presence of portal vein thrombosis. Am J Transplant 2007; 7: 454.
Cavoportal Hemitransposition Associated to Portoportal Anastomosis for Liver Transplant in Portomesenteric Thrombosis e read with interest the correspondence by Dokmak et al. (1), which makes reference to the recently published systematic review (2); both papers underline how the fascinating issue of nonneoplastic portomesenteric thrombosis (NPMT) in the setting of liver transplantation is still open to refinements and evolution. In particular, two relevant and deeply intertwined issues emerge, which merit clarification. Foremost, NPMT
W
should probably no longer be considered a contraindication for liver transplantation. Secondly, there is still the need for a better standardization of technical solutions to the multiple and variable anatomoclinical situations that can be encountered. Increasing technical experience in portal thrombectomy as well as in finding solutions to reperfuse the graft in the presence of a complete thrombosis of the portomesenteric axis (1, 3, 4) have
reduced the prevalence of posttransplantation mortality to less than 20% in most experiences (5Y7). Based on this, a patient should not be refused liver transplantation, independently from the grade of thrombosis, as long as an acceptable surgical risk dictated by comorbidities is present and an adequate transplant benefit is expected. Indeed, this is the case in most liver transplant candidates with NPMT, who present a high mortality risk in the absence of an
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
