j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 9 ( 2 0 1 4 ) 3 2 1 e3 2 5
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Remain recipient partial liver during liver transplant after Hassab Jianhua Rao, MD, PhD,1 Yong Sun, MD, PhD,1 Haoming Zhou, MD, PhD, Guoqiang Li, MD, PhD, Xiaofeng Qian, MD, PhD, Xuehao Wang, MD, PhD, Feng Zhang, MD, PhD,** and Ling Lu, MD, PhD* Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Department of liver surgery, First Affiliated Hospital of Nanjing Medical University; Nanjing, P.R. China
article info
abstract
Article history:
Background: The Hassab procedure is the primary method for treating and preventing
Received 16 August 2013
recurrent esophagogastric variceal bleeding in portal hypertension patients. These patients
Received in revised form
have worsening liver function and eventually require liver transplantation. Abnormal
21 February 2014
anatomical structures and severe tissue adhesion caused by the Hassab procedure increase
Accepted 24 February 2014
the risks of transplantation. We investigated the safety and efficacy of retaining part of the
Available online 5 March 2014
left lateral hepatic lobe during transplantation. Materials and methods: This retrospective study evaluated outcomes in 22 patients who
Keywords:
underwent the Hassab procedure followed by liver transplantation. The patients were
Liver transplantation
separated into two groups: group A (complete liver resection, n ¼ 14) and group B
Hassab procedure
(incomplete liver resection with left lateral remnant, n ¼ 8). We statistically analyzed pre-,
Safety
intra-, and post-operative variables in both groups.
Efficacy
Results: Preoperative demographic data showed no significant differences between the groups. Operation time was significantly greater in group A (10.85 0.79 h) than in group B (7.25 0.59 h), and median blood loss (2807 472 mL) was significantly greater in group A than in group B (1023 141 mL, P < 0.05 for both). Overall complication rates were not significantly different; the 1- and 3-y survival rates were 85.7% and 71.4% for group A and 87.5% and 75.0% for group B, respectively (P > 0.05). Conclusions: Retention of some left hepatic lobe tissue during liver transplantation after the Hassab procedure is safe and feasible because it increases the success rate by reducing surgical difficulty and time. ª 2014 Elsevier Inc. All rights reserved.
* Corresponding author. Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Department of liver surgery, First Affiliated Hospital of Nanjing Medical University; Guangzhou road No. 300, Nanjing 210029, P.R. China. Tel.: þ86 25 83718836 6476; fax: þ86 25 83672106. ** Corresponding author. Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Department of liver surgery, First Affiliated Hospital of Nanjing Medical University; Guangzhou road No. 300, Nanjing 210029, P.R. China. Tel.: þ86 25 83718836 6476; fax: þ86 25 83672106. E-mail addresses: [email protected] (L. Lu), [email protected] (F. Zhang). 1 These authors contributed equally to this work. 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.02.046
322
1.
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 9 ( 2 0 1 4 ) 3 2 1 e3 2 5
Introduction
Cirrhosis often causes portal hypertension with a pathologic increase in the portal pressure gradient [1,2]. Portal hypertension can lead to the severe complications of esophagogastric variceal bleeding (EGVB) and thrombocytopenia due to hypersplenism. EGVB has a 10%e50% mortality rate [3]. Although endoscopic surgery and drugs have been widely used to treat EGVB, the Hassab procedure (splenectomy with gastroesophageal devascularization) is still the primary method used to treat and prevent recurrent EGVB in East Asia [4,5]. The Hassab procedure prevents EGVB but does not affect cirrhosis and progression to end-stage liver disease; so, patients usually require liver transplantation. However, performing liver transplantation in patients who have undergone the Hassab procedure can be more difficult because of the creation of abnormal anatomical structures, severe tissue adhesion, and portal or splenic vein thrombosis. These conditions make the transplant procedure more cumbersome, leading to higher morbidity and mortality in patients [6,7]. We developed a novel method of liver transplantation that retained part of the recipient’s liver; this method should make the procedure easier for the surgeon, thus reducing operation time and blood loss. In this study, we retrospectively investigated the safety and efficacy of our modified liver transplantation procedure that retains part of the original liver.
2.
Materials and methods
2.1.
Study group
2.2.
A detailed description of the procedure has been documented in previous investigations [8]. Here, native liver transplants were given to patients who previously underwent a Hassab procedure. Briefly, the surgery was performed under general anesthesia through a right subcostal incision with an extension to the upper midline. After thorough abdominal exploration, the liver was separated as much as possible. After inflow occlusion, liver resection was quickly performed as much as possible. In some cases, it was too difficult to dissociate the left hepatic lobe from adhering to the stomach or surrounding tissue; in these cases, the partial left hepatic lobe was not resected (Fig. 1). All of the grafts were preserved and flushed using the University of Wisconsin solution. Then, Portal vein, hepatic artery, and bile duct reconstruction was performed.
2.3.
Immunosuppressive regimen and antiviral protocol
Immunosuppressive therapy after transplantation consisted of tacrolimus, mycophenolate mofetil, and a corticosteroid. Steroid therapy was reduced rapidly whenever possible. Pulse corticosteroid therapy was administered to patients with rejection. Lamivudine and hepatitis B immune globulin were used to prevent hepatitis B virus (HBV) recurrence in patients with a positive hepatitis B surface antigen. Postoperative HBV recurrence was defined as the reappearance of hepatitis B surface antigen or HBV DNA in the serum.
2.4.
From January 2006 to December 2011, 22 consecutive patients with a previous Hassab procedure underwent liver transplantation at our center. Liver transplantation was performed using the “piggyback technique,” a standard procedure that does not use venovenous bypass [8]. All of the transplantations were approved by the ethics committee of the First Affiliated Hospital of Nanjing Medical University. The patients were separated into two groups: group A (complete liver resection, n ¼ 14) and group B (incomplete liver resection with left lateral remnant, n ¼ 8).
Surgical procedure
Data collection and follow-up
The following preoperative and intraoperative data for both groups were collected: age, gender, body mass index (BMI), model for end-stage liver disease (MELD) score, Child-Pugh score, indication for transplantation, renal function, blood coagulation indexes (including prothrombin time, international normalized ratio, activated partial thromboplastin time, thrombin time, and fibrinogen), operative time, intraoperative blood loss, and amount of red blood cell (RBC) transfusion. Severe early postoperative complications were defined as a complication occurring within 3 mo after transplantation. Renal dysfunction was defined as a creatinine
Fig. 1 e Schematic diagram of the operation: (A) the left hepatic lobe adhered to stomach and surrounding tissue after Hassab procedure; (B) disease liver was resected as much as possible, but the partial left hepatic lobe can not be resected; (C) graft was implanted. (Color version of figure is available online.)
323
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 9 ( 2 0 1 4 ) 3 2 1 e3 2 5
Table 1 e Pre- and intra-operative data for groups A and B. Variables Recipient variables Age (y) Gender (male/ female) BMI MELD score Child-Pugh score Renal dysfunction Initial Hb level (g/L) Coagulation status PT (s) INR APTT (s) TT (s) FIB (g/L) CIT Indication for LT HBV-related cirrhosis HCV-related cirrhosis Alcoholic cirrhosis Primary biliary cirrhosis Surgical variables Operative time (h) Blood loss (mL) RBC transfusion (U)
Group A
46.21 2.98 11
Group B
43.13 3.17 5
Table 2 e Postoperative data for groups A and B. P value 0.512 0.416
20.50 1.11 16.50 1.88 9.71 0.87 3 110.17 24.78
19.50 17.57 9.13 1 106.42
1.09 2.03 1.23
20.36 0.97 42.72 25.31 2.39 4.78
3.42 0.08 3.56 3.01 1.08 3.17
0.341 0.680 0.695 0.532 0.750 0.821 0.562
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Remain recipient partial liver during liver transplant after Hassab Jianhua Rao, MD, PhD,1 Yong Sun, MD, PhD,1 Haoming Zhou, MD, PhD, Guoqiang Li, MD, PhD, Xiaofeng Qian, MD, PhD, Xuehao Wang, MD, PhD, Feng Zhang, MD, PhD,** and Ling Lu, MD, PhD* Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Department of liver surgery, First Affiliated Hospital of Nanjing Medical University; Nanjing, P.R. China
article info
abstract
Article history:
Background: The Hassab procedure is the primary method for treating and preventing
Received 16 August 2013
recurrent esophagogastric variceal bleeding in portal hypertension patients. These patients
Received in revised form
have worsening liver function and eventually require liver transplantation. Abnormal
21 February 2014
anatomical structures and severe tissue adhesion caused by the Hassab procedure increase
Accepted 24 February 2014
the risks of transplantation. We investigated the safety and efficacy of retaining part of the
Available online 5 March 2014
left lateral hepatic lobe during transplantation. Materials and methods: This retrospective study evaluated outcomes in 22 patients who
Keywords:
underwent the Hassab procedure followed by liver transplantation. The patients were
Liver transplantation
separated into two groups: group A (complete liver resection, n ¼ 14) and group B
Hassab procedure
(incomplete liver resection with left lateral remnant, n ¼ 8). We statistically analyzed pre-,
Safety
intra-, and post-operative variables in both groups.
Efficacy
Results: Preoperative demographic data showed no significant differences between the groups. Operation time was significantly greater in group A (10.85 0.79 h) than in group B (7.25 0.59 h), and median blood loss (2807 472 mL) was significantly greater in group A than in group B (1023 141 mL, P < 0.05 for both). Overall complication rates were not significantly different; the 1- and 3-y survival rates were 85.7% and 71.4% for group A and 87.5% and 75.0% for group B, respectively (P > 0.05). Conclusions: Retention of some left hepatic lobe tissue during liver transplantation after the Hassab procedure is safe and feasible because it increases the success rate by reducing surgical difficulty and time. ª 2014 Elsevier Inc. All rights reserved.
* Corresponding author. Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Department of liver surgery, First Affiliated Hospital of Nanjing Medical University; Guangzhou road No. 300, Nanjing 210029, P.R. China. Tel.: þ86 25 83718836 6476; fax: þ86 25 83672106. ** Corresponding author. Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Department of liver surgery, First Affiliated Hospital of Nanjing Medical University; Guangzhou road No. 300, Nanjing 210029, P.R. China. Tel.: þ86 25 83718836 6476; fax: þ86 25 83672106. E-mail addresses: [email protected] (L. Lu), [email protected] (F. Zhang). 1 These authors contributed equally to this work. 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.02.046
322
1.
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 9 ( 2 0 1 4 ) 3 2 1 e3 2 5
Introduction
Cirrhosis often causes portal hypertension with a pathologic increase in the portal pressure gradient [1,2]. Portal hypertension can lead to the severe complications of esophagogastric variceal bleeding (EGVB) and thrombocytopenia due to hypersplenism. EGVB has a 10%e50% mortality rate [3]. Although endoscopic surgery and drugs have been widely used to treat EGVB, the Hassab procedure (splenectomy with gastroesophageal devascularization) is still the primary method used to treat and prevent recurrent EGVB in East Asia [4,5]. The Hassab procedure prevents EGVB but does not affect cirrhosis and progression to end-stage liver disease; so, patients usually require liver transplantation. However, performing liver transplantation in patients who have undergone the Hassab procedure can be more difficult because of the creation of abnormal anatomical structures, severe tissue adhesion, and portal or splenic vein thrombosis. These conditions make the transplant procedure more cumbersome, leading to higher morbidity and mortality in patients [6,7]. We developed a novel method of liver transplantation that retained part of the recipient’s liver; this method should make the procedure easier for the surgeon, thus reducing operation time and blood loss. In this study, we retrospectively investigated the safety and efficacy of our modified liver transplantation procedure that retains part of the original liver.
2.
Materials and methods
2.1.
Study group
2.2.
A detailed description of the procedure has been documented in previous investigations [8]. Here, native liver transplants were given to patients who previously underwent a Hassab procedure. Briefly, the surgery was performed under general anesthesia through a right subcostal incision with an extension to the upper midline. After thorough abdominal exploration, the liver was separated as much as possible. After inflow occlusion, liver resection was quickly performed as much as possible. In some cases, it was too difficult to dissociate the left hepatic lobe from adhering to the stomach or surrounding tissue; in these cases, the partial left hepatic lobe was not resected (Fig. 1). All of the grafts were preserved and flushed using the University of Wisconsin solution. Then, Portal vein, hepatic artery, and bile duct reconstruction was performed.
2.3.
Immunosuppressive regimen and antiviral protocol
Immunosuppressive therapy after transplantation consisted of tacrolimus, mycophenolate mofetil, and a corticosteroid. Steroid therapy was reduced rapidly whenever possible. Pulse corticosteroid therapy was administered to patients with rejection. Lamivudine and hepatitis B immune globulin were used to prevent hepatitis B virus (HBV) recurrence in patients with a positive hepatitis B surface antigen. Postoperative HBV recurrence was defined as the reappearance of hepatitis B surface antigen or HBV DNA in the serum.
2.4.
From January 2006 to December 2011, 22 consecutive patients with a previous Hassab procedure underwent liver transplantation at our center. Liver transplantation was performed using the “piggyback technique,” a standard procedure that does not use venovenous bypass [8]. All of the transplantations were approved by the ethics committee of the First Affiliated Hospital of Nanjing Medical University. The patients were separated into two groups: group A (complete liver resection, n ¼ 14) and group B (incomplete liver resection with left lateral remnant, n ¼ 8).
Surgical procedure
Data collection and follow-up
The following preoperative and intraoperative data for both groups were collected: age, gender, body mass index (BMI), model for end-stage liver disease (MELD) score, Child-Pugh score, indication for transplantation, renal function, blood coagulation indexes (including prothrombin time, international normalized ratio, activated partial thromboplastin time, thrombin time, and fibrinogen), operative time, intraoperative blood loss, and amount of red blood cell (RBC) transfusion. Severe early postoperative complications were defined as a complication occurring within 3 mo after transplantation. Renal dysfunction was defined as a creatinine
Fig. 1 e Schematic diagram of the operation: (A) the left hepatic lobe adhered to stomach and surrounding tissue after Hassab procedure; (B) disease liver was resected as much as possible, but the partial left hepatic lobe can not be resected; (C) graft was implanted. (Color version of figure is available online.)
323
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 9 ( 2 0 1 4 ) 3 2 1 e3 2 5
Table 1 e Pre- and intra-operative data for groups A and B. Variables Recipient variables Age (y) Gender (male/ female) BMI MELD score Child-Pugh score Renal dysfunction Initial Hb level (g/L) Coagulation status PT (s) INR APTT (s) TT (s) FIB (g/L) CIT Indication for LT HBV-related cirrhosis HCV-related cirrhosis Alcoholic cirrhosis Primary biliary cirrhosis Surgical variables Operative time (h) Blood loss (mL) RBC transfusion (U)
Group A
46.21 2.98 11
Group B
43.13 3.17 5
Table 2 e Postoperative data for groups A and B. P value 0.512 0.416
20.50 1.11 16.50 1.88 9.71 0.87 3 110.17 24.78
19.50 17.57 9.13 1 106.42
1.09 2.03 1.23
20.36 0.97 42.72 25.31 2.39 4.78
3.42 0.08 3.56 3.01 1.08 3.17
0.341 0.680 0.695 0.532 0.750 0.821 0.562
