S32
www.transplantjournal.com
CONCLUSION In conclusion, our new strategy including portal pressure control increases donor safety and provides acceptable recipient outcomes.
REFERENCES 1. 2.
3.
Iida T, Ogura Y, Oike F, et al. Surgery-related morbidity in living donors for liver transplantation. Transplantation 2010; 89: 1276. Ogura Y, Hori T, El Moghazy WM, et al. Portal pressure G15 mm Hg is a key for successful adult living donor liver transplantation utilizing smaller grafts than before. Liver Transpl 2010; 16: 718. Kaido T, Mori A, Ogura Y, et al. Lower limit of the graft-to-recipient weight ratio can be safely reduced to 0.6% in adult-to-adult living donor liver transplantation in combination with portal pressure control. Transplant Proc 2011; 43: 2391.
SECTION 8. MANAGEMENT OF PORTAL VENOUS COMPLICATIONS IN PEDIATRIC LIVING DONOR LIVER TRANSPLANTATION
Yu-Fan Cheng,1 Hsin-You Ou,1 Chun-Yen Yu,1 Leo Leung-Chit Tsang,1 Tung-Liang Huang,1 Tai-Yi Chen,1 Allan Concejero,2 Chih-Chi Wang,2 Shih-Ho Wang,2 Tsan-Shiun Lin,2 Yueh-Wei Liu,2 Chin-Hsiang Yang,2 Chee-Chien Yong,2 King-Wah Chiu,3 Bruno Jawan,4 Hock-Liew Eng,5 and Chao-Long Chen2,6 Abstract. Portal vein (PV) complications after living donor liver transplant (LDLT) have been a major concern in pediatric liver transplantation. The incidence of PV complications is more in pediatric (0%Y33%) than in adult recipients. Early diagnosis and treatment of PV complications may ensure optimal graft function and good recipient survival. Small preoperation PV size (G4 mm) and slow portal flow (G10 cm/s) combined with lower hepatic artery resistance index (G0.65) are strong warning signs that may predict the development of post LDLT PV complications. Portal vein angioplasty/stenting is conventionally performed through the percutaneous transhepatic approach; however, this can also be performed through transjugular, trans-splenic, and intraoperative
This work was supported by Grant NSC 96-231-B-182A-009 and NSC 94-231-B182A-009 from the National Science Council, Taiwan. The authors declare no conflicts of interest. 1 Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Taiwan. 2 Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan. 3 Division of Hepatogastroenterology, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan. 4 Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Taiwan. 5 Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Taiwan. 6 Address correspondence to: Chao-Long Chen, M.D., Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Tai-Pei Road, Niao-Sung, Kaohsiung 83305, Taiwan. E-mail: [email protected] Dr. Yu-Fan Cheng and Dr. Hsin-You Ou contributed equally to this work.
Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9708-00 DOI: 10.1097/TP.0000000000000060
Transplantation
& Volume 97, Number 8S, April 27, 2014
approaches. Depending on the situation, using optimal method is the key point to minimize complication (5%) and gain high success rate (80%). PV occlusion of greater than 1 year with cavernous transformation seems to be a factor causing technical failure. Good patency rate (100%) with self-expandable metallic stents was noted in long-term follow-up. In conclusion, PV stent placement is an effective, long-term treatment modality to manage PV complications after pediatric LDLT. Early diagnosis and treatment are essential to maximize the use of stent placement and achieve good success rates. Keywords: Portal vein occlusion, Portal vein complication, Stent, Living donor liver transplantation, Pediatric liver transplantation.
iving donor liver transplant (LDLT) is an optimal solution for the urgent demand for liver graft (1). Although portal vein (PV) abnormalities are rather uncommon and merely occur in 2% to 13% of transplant recipients, some devastating complications are troublesome and have been an imperative challenge for postoperative management (2, 3).
L
Risk Factors There are certain factors that put recipients at the risk of developing PV complications. A PV with small diameter, history of preliver transplantation (LT) portal vein thrombosis (PVT), surgical shunt operation before LT, and splenectomy are known risk factors for the development of PVT in orthotopic LT (4). In the pediatric age group, the risk factors include preexisting portosystemic shunts with ensuing decreased PV flow, graft interposition, the age at first LT (children G1 year old), weight (G6 kg), and need for retransplantation (5Y7). Chardot et al. reported that PV diameter, age and weight at transplantation, and emergency transplantation are significantly associated with PV complications in BA (8). In Chardot’s biliary atresia (BA) series, most PVT occurred in the early stage (5, 9). Few reports focus on late-onset PVT with a long-term follow-up period. Clinical Signs and Symptoms Initially, most patients are asymptomatic and increased liver function tests are seldom. In late phase, obstruction of the PV contributes to thrombus or stenosis formation at the anastomosis site. The onset of ascites, variceal bleeding, splenomegaly, and pancytopenia are the typical clinical scenarios associated with PV stenosis. Although these symptoms could also be a result of occlusion of the hepatic vein, statistically, the PV bears a relatively higher tendency for occlusion. Imaging Diagnosis Early detection and diagnosis of any PV complication is essential for the prevention of late PV complicationrelated graft loss. Regular evaluation of PV flow by Doppler ultrasound is, thus, important (10). High-risk patients should be identified, and early signs of developing PVT must be sought to diagnose early PVT. Small PV size (G4 mm) and slow portal flow (G10 cm/sec) combined with lower hepatic artery resistance index (G0.65) are strong warning signs predicting the development of post-LDLT PV thrombosis in BA patients that require close monitoring (11). Jet flow phenomenon of portal flow and poststenotic dilatation of
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
* 2014 Lippincott Williams & Wilkins
the PV are easily found in patients with severe PV stenosis. Splenomegaly and ascites could also be clues to suggest the presence of portal vein complications. Computed tomography angiography and magnetic resonance angiography could provide strong supports for PVT diagnosis. Confirmation and common therapeutic interventions for all venous complications are done by invasive angiography. Indications Patients with normal liver function and prehepatic portal hypertension signs and symptoms (ascites, persisted splenomegaly, pancytopenia, gastroesophageal variceal bleeding, etc) should undergo imaging survey. If with findings of high-grade stenosis (950%), portal vein thrombosis or progressive portal vein stenosis must be entertained and patient should undergo portal venous angiography. For patients with severe stenotis, portal vein stenting should be done to improve their clinical signs and symptoms (12).
APPROACHES TO PORTAL VEIN STENTING Interventional stent placement was the initial treatment of choice in all cases. Four different methods (to access the PV) were used namely percutaneous transhepatic, percutaneous trans-splenic, transjugular, and intraoperative. Percutaneous Transhepatic Portal vein angioplasty/stenting is conventionally performed through percutaneous transhepatic approach. This approach is easy with high successful rate. However, hemoperitoneum and hemothorax are the most common complications observed (13). Percutaneous Trans-splenic The trans-splenic approach is less injurious to the transplanted liver graft and is recommended in pediatric patients because of the upper location of the graft in the left subphrenic region (14). It is performed by puncturing the splenic vein with a 21-gauge Chiba needle (Cook, Bloomington, IN) under ultrasonographic and fluoroscopic guidance. The needle was changed to a 4-French coaxial dilator and a 7-French sheath (Terumo, Tokyo, Japan) over a 0.035-inch angled hydrophilic guide wire (Terumo) after confirmation that the needle was in the splenic vein. Direct main portal venography and the pressure gradient across the stenosis were then obtained. Engorgement of intraparenchymal hepatic artery with prominent Doppler ultrasound (DUS) arterial flow is usually seen in poor portal flow patients, especially in those with complete PV vein occlusion. A small-sized PV with no flow visualization is difficult to approach and may need several attempts to puncture. In this situation, parenchymal HA pseudoaneurysm can be the complication in pediatric LT during PV intervention (15). In our study, if the transhepatic approach is difficult to perform and is disadvantageous, the trans-splenic approach may be an alternative method. Transjugular In selecting the route to access the PV, bleeding tendency or massive ascites is considered a relative contraindication to the transhepatic or trans-splenic approaches (16). Although the transjugular approach is suitable for conditions where bleeding tendency or massive ascites is present, it is difficult to puncture the PV through this approach
Chen et al.
S33
especially in cases of total PV occlusion. Furthermore, the spatial relation between the hepatic vein and the PV after LT is another factor to consider especially in those who received a left lobe graft. Intraoperative PV Access The intraoperative portal vein stent placement is another method for managing patients with portal vein abnormalities. After reperfusion, when insufficient portal flow was detected by DUS, direct portogram can be performed and stent can be placed as an alternative procedure when surgical intervention failed. We report two cases in which this procedure was used to guide intraoperative PV stent placement through the inferior mesenteric vein approach using of the stump of the segment 4 PV in pediatric living donor liver transplant recipients (17).
COMPLICATIONS Hemoperitoneum and hemothorax are common complications in percutaneous transhepatic portal venous angioplasty and stenting (13). The trans-splenic approach is less injurious to the transplanted liver graft and is recommended in pediatric patients. A procedure-related complication occurred in 1 patient who had rupture of the splenic vein after puncturing with some contrast media extravasation. Immediate stenting was performed to relieve the high portal pressure. No further surgical intervention was required. This patient recovered one week later with no hemoperitoneum. The trans-splenic approach may be an alternative approach. Familiarity with the technique of vascular puncture under ultrasound-guidance is necessary for the procedure. Gentle and delicate manipulation of the puncture needle and guide wire advancement through the engorged thin-walled splenic vein is important.
FOLLOW-UP After stent placement, intravenous anticoagulation agent was given for 7 days to maintain an international normalized ratio of 1.5Y2.0. Oral antiplatelet overlapping with antiplatelets (aspirin 100 mg/day and/or dipyridamole 75 mg/day) and was given for 6 months. In patients with coagulopathy, oral antiplatelet was started only when their coagulation function had normalized. Good patency rate (100%) with self-expandable metallic stents was noted in long-term follow-up. A stented PV is not expected to increase in size as in a native PV, and a relative PV stenosis may occur in adult life. However, we are confident that a 7-mm size PV is able to supply sufficient amount for portal flow even in adults.
CONCLUSION In conclusion, portal vein stent placement is an effective and long-lasting treatment modality in treating of the portal venous occlusion. Early detection and diagnosis is essential for curative effect of stent placement and early treatment can achieve an excellent successful rate. Planning the best route to enter the portal venous system in deploying of the vascular stent is essential for yielding a safe and successful outcome.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S34
www.transplantjournal.com
Transplantation
& Volume 97, Number 8S, April 27, 2014
REFERENCES 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Fan ST, Lo CM, Liu CL. Experience of donor right lobe hepatectomy in adult-to-adult live donor liver transplantation: clinical analysis of 89 cases. Hepatobiliary Pancreat Dis Int 2002; 1: 166. Duffy JP, Hong JC, Farmer DG, et al. Vascular complications of orthotopic liver transplantation: experience in more than 4,200 patients. J Am Coll Surg 2009; 208: 896. Millis JM, Seaman DS, Piper JB, et al. Portal vein thrombosis and stenosis in pediatric liver transplantation. Transplantation 1996; 62: 748. Lerut J, Tzakis AG, Bron K, et al. Complications of venous reconstruction in human orthotopic liver transplantation. Ann Surg 1987; 205: 404. Ueda M, Oike F, Kasahara M, et al. Portal vein complications in pediatric living donor liver transplantation using left-side grafts. Am J Transplant 2008; 8: 2097. Unsinn KM, Freund MC, et al. Spectrum of imaging findings after pediatric liver transplantation: part 2, posttransplantation complications. Am J Roentgenol 2003; 181: 1139. Lo´pez Santamarı´a M, Ga´mez M, Murcia J, et al. Pre-hepatic portal hypertension as a late complication of liver transplantation in children. Cir Pediatr 2001; 14: 135. Chardot C, Herrera JM, Debray D, et al. Portal vein complications after liver transplantation for biliary atresia. Liver Transplant Surg 1997; 3: 351. Lucianetti A, Guizzetti M, Bertani A, et al. Liver transplantation in children weighing less than 6 kg. The Bergamo experience. Transplant Proc 2005; 37: 1143. Huang TL, Cheng YF, Chen TY, et al. Doppler ultrasound evaluation of postoperative portal vein stenosis in adult living donor liver transplantation. Transplant Proc 2010; 42: 879. Ou HY, Concejero AM, Huang TL, et al. Portal vein thrombosis in biliary atresia patients after living donor liver transplantation. Surgery 2011; 149: 40. Cheng YF, Ou HY, Tsang LL, et al. Vascular stents in the management of portal venous complications in living donor liver transplantation. Am J Transplant 2010; 10: 1276. Ko GY, Sung KB, Yoon HK, et al. Early posttransplantation portal vein stenosis following living donor liver transplantation: percutaneous transhepatic primary stent placement. Liver Transpl 2007; 13: 530. Cheng YF, Ou HY, Tsang LL, et al. Interventional percutaneous trans-splenic approach in the management of portal venous occlusion after living donor liver transplantation. Liver Transpl 2009; 15: 1378. Seu P, Shackleton C, Shaked A, et al. Improved results of the liver transplantation in patients with portal vein thrombosis. Arch Surg 1996; 131: 840. Otto G, Richter GM, Theilmann L, et al. [Liver transplantation after trans-jugular intrahepatic portosystemic stent shunt]. Chirurg 1992; 63: 730. Chen CL, Concejero AM, Ou HY, et al. Intraoperative portal vein stent placement in pediatric living donor liver transplantation. J Vasc Interv Radiol 2012; 23: 724.
SECTION 9. TECHNICAL DETAILS OF MICROSURGICAL BILIARY RECONSTRUCTION IN LIVING DONOR LIVER TRANSPLANTATION
Tsan-Shiun Lin,1 Chao-Long Chen,1,3 Allan M Concejero,1 Anthony Q. Yap,1 Yu-Hung Lin,1 Chun-Yi Liu,1 Yuan-Cheng Chiang,1 Chih-Chi Wang,1 Shih-Ho Wang,1 Chih-Che Lin,1 Chee-Chien Yong,1 and Yu-Fan Cheng2
Abstract. Small size and multiple ducts, particularly in right lobe liver grafts, are major factors that contribute to biliary complications in living donor liver transplantation. To improve the outcome of biliary reconstruction, further investigation and refinement of reconstruction techniques and management strategies are necessary. From March 2006 to June 2012, routine MBR was performed in 584 grafts in 581 consecutive LDLT (including 3 dual graft transplants). All biliary reconstructions were performed using microsurgical technique by a single microsurgeon. The classification of biliary reconstruction was based according to the number of ducts in the graft, the manner in which these ducts were reconstructed (with or without ductoplasty), and the conduit used (recipient duct or jejunum) to reconstruct the biliary tree. In ductto-duct reconstruction, posterior wall first technique by using interrupted suture and continuous running and interrupted tie technique (combined method) for the anterior wall were performed. Recipient reduction ductoplasty was done, if necessary. In duct-to-jejunum reconstruction, enterotomy was performed first under microscope; then, the serosal and mucosal layers were sutured together using 8-0 prolene to facilitate the anastomosis. Posterior wall first by using interrupted suture technique and combined method for the anterior wall were also performed. Overall, there were 397 right and 184 left lobe grafts. Single duct opening was noted in 440 (75.34%), two duct openings in 135(23.12%), and three duct openings in 9 (1.54%) grafts. Ductto-duct anastomosis was performed in 473 (81%) and duct-tojejunum Roux limb in 111 (19%) biliary reconstructions. Size discrepancy in the graft and recipient ducts was noted in 394 (83.3%) reconstructions. The overall biliary complication was 7.9%. These included 19 (3.3%) bile leaks and 27 (4.6%) biliary strictures. The routine use of MBR capably surmounts the difficulties brought about by the anatomic variations and the size discrepancies between the graft and recipient hepatic ducts with excellent outcome. Keywords: Biliary reconstruction, Microsurgical technique, Living donor liver transplantation, Biliary complications, Biliary outcome.
iliary complications (BC) following LDLT have remained high at a rate of 16% to 67% (1Y10). Small size and multiple ducts, particularly in the right lobe liver grafts are the major factors of such results (4). To overcome these complexities brought by anatomic variations, our institution has routinely used microsurgical biliary reconstruction (MBR) in LDLT since 2006 (11). At the onset of applying the MBR technique, recipient reduction ductoplasty was performed by a liver transplant surgeon without the aid of an operating microscope; then, the anastomosis was performed by the microsurgeon under an operating microscope with a magnification of 5 to 15. This practice resulted in an unacceptably high rate of BC (46.7%) in
B
This work was presented in the video session during the 2013 Asian summit on living donor liver transplantation held in Kaohsiung, Taiwan, January 12, 2013. The authors declare no funding or conflicts of interest. 1 Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. 2 Liver Transplantation Program and Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. 3 Address correspondence to: Chao-Long Chen, M.D., Liver Transplantation Program, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Sung, Kaohsiung, 83305 Taiwan. E-mail: [email protected]
Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9708-00 DOI: 10.1097/TP.0000000000000060
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.transplantjournal.com
CONCLUSION In conclusion, our new strategy including portal pressure control increases donor safety and provides acceptable recipient outcomes.
REFERENCES 1. 2.
3.
Iida T, Ogura Y, Oike F, et al. Surgery-related morbidity in living donors for liver transplantation. Transplantation 2010; 89: 1276. Ogura Y, Hori T, El Moghazy WM, et al. Portal pressure G15 mm Hg is a key for successful adult living donor liver transplantation utilizing smaller grafts than before. Liver Transpl 2010; 16: 718. Kaido T, Mori A, Ogura Y, et al. Lower limit of the graft-to-recipient weight ratio can be safely reduced to 0.6% in adult-to-adult living donor liver transplantation in combination with portal pressure control. Transplant Proc 2011; 43: 2391.
SECTION 8. MANAGEMENT OF PORTAL VENOUS COMPLICATIONS IN PEDIATRIC LIVING DONOR LIVER TRANSPLANTATION
Yu-Fan Cheng,1 Hsin-You Ou,1 Chun-Yen Yu,1 Leo Leung-Chit Tsang,1 Tung-Liang Huang,1 Tai-Yi Chen,1 Allan Concejero,2 Chih-Chi Wang,2 Shih-Ho Wang,2 Tsan-Shiun Lin,2 Yueh-Wei Liu,2 Chin-Hsiang Yang,2 Chee-Chien Yong,2 King-Wah Chiu,3 Bruno Jawan,4 Hock-Liew Eng,5 and Chao-Long Chen2,6 Abstract. Portal vein (PV) complications after living donor liver transplant (LDLT) have been a major concern in pediatric liver transplantation. The incidence of PV complications is more in pediatric (0%Y33%) than in adult recipients. Early diagnosis and treatment of PV complications may ensure optimal graft function and good recipient survival. Small preoperation PV size (G4 mm) and slow portal flow (G10 cm/s) combined with lower hepatic artery resistance index (G0.65) are strong warning signs that may predict the development of post LDLT PV complications. Portal vein angioplasty/stenting is conventionally performed through the percutaneous transhepatic approach; however, this can also be performed through transjugular, trans-splenic, and intraoperative
This work was supported by Grant NSC 96-231-B-182A-009 and NSC 94-231-B182A-009 from the National Science Council, Taiwan. The authors declare no conflicts of interest. 1 Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Taiwan. 2 Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan. 3 Division of Hepatogastroenterology, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan. 4 Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Taiwan. 5 Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Taiwan. 6 Address correspondence to: Chao-Long Chen, M.D., Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Tai-Pei Road, Niao-Sung, Kaohsiung 83305, Taiwan. E-mail: [email protected] Dr. Yu-Fan Cheng and Dr. Hsin-You Ou contributed equally to this work.
Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9708-00 DOI: 10.1097/TP.0000000000000060
Transplantation
& Volume 97, Number 8S, April 27, 2014
approaches. Depending on the situation, using optimal method is the key point to minimize complication (5%) and gain high success rate (80%). PV occlusion of greater than 1 year with cavernous transformation seems to be a factor causing technical failure. Good patency rate (100%) with self-expandable metallic stents was noted in long-term follow-up. In conclusion, PV stent placement is an effective, long-term treatment modality to manage PV complications after pediatric LDLT. Early diagnosis and treatment are essential to maximize the use of stent placement and achieve good success rates. Keywords: Portal vein occlusion, Portal vein complication, Stent, Living donor liver transplantation, Pediatric liver transplantation.
iving donor liver transplant (LDLT) is an optimal solution for the urgent demand for liver graft (1). Although portal vein (PV) abnormalities are rather uncommon and merely occur in 2% to 13% of transplant recipients, some devastating complications are troublesome and have been an imperative challenge for postoperative management (2, 3).
L
Risk Factors There are certain factors that put recipients at the risk of developing PV complications. A PV with small diameter, history of preliver transplantation (LT) portal vein thrombosis (PVT), surgical shunt operation before LT, and splenectomy are known risk factors for the development of PVT in orthotopic LT (4). In the pediatric age group, the risk factors include preexisting portosystemic shunts with ensuing decreased PV flow, graft interposition, the age at first LT (children G1 year old), weight (G6 kg), and need for retransplantation (5Y7). Chardot et al. reported that PV diameter, age and weight at transplantation, and emergency transplantation are significantly associated with PV complications in BA (8). In Chardot’s biliary atresia (BA) series, most PVT occurred in the early stage (5, 9). Few reports focus on late-onset PVT with a long-term follow-up period. Clinical Signs and Symptoms Initially, most patients are asymptomatic and increased liver function tests are seldom. In late phase, obstruction of the PV contributes to thrombus or stenosis formation at the anastomosis site. The onset of ascites, variceal bleeding, splenomegaly, and pancytopenia are the typical clinical scenarios associated with PV stenosis. Although these symptoms could also be a result of occlusion of the hepatic vein, statistically, the PV bears a relatively higher tendency for occlusion. Imaging Diagnosis Early detection and diagnosis of any PV complication is essential for the prevention of late PV complicationrelated graft loss. Regular evaluation of PV flow by Doppler ultrasound is, thus, important (10). High-risk patients should be identified, and early signs of developing PVT must be sought to diagnose early PVT. Small PV size (G4 mm) and slow portal flow (G10 cm/sec) combined with lower hepatic artery resistance index (G0.65) are strong warning signs predicting the development of post-LDLT PV thrombosis in BA patients that require close monitoring (11). Jet flow phenomenon of portal flow and poststenotic dilatation of
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
* 2014 Lippincott Williams & Wilkins
the PV are easily found in patients with severe PV stenosis. Splenomegaly and ascites could also be clues to suggest the presence of portal vein complications. Computed tomography angiography and magnetic resonance angiography could provide strong supports for PVT diagnosis. Confirmation and common therapeutic interventions for all venous complications are done by invasive angiography. Indications Patients with normal liver function and prehepatic portal hypertension signs and symptoms (ascites, persisted splenomegaly, pancytopenia, gastroesophageal variceal bleeding, etc) should undergo imaging survey. If with findings of high-grade stenosis (950%), portal vein thrombosis or progressive portal vein stenosis must be entertained and patient should undergo portal venous angiography. For patients with severe stenotis, portal vein stenting should be done to improve their clinical signs and symptoms (12).
APPROACHES TO PORTAL VEIN STENTING Interventional stent placement was the initial treatment of choice in all cases. Four different methods (to access the PV) were used namely percutaneous transhepatic, percutaneous trans-splenic, transjugular, and intraoperative. Percutaneous Transhepatic Portal vein angioplasty/stenting is conventionally performed through percutaneous transhepatic approach. This approach is easy with high successful rate. However, hemoperitoneum and hemothorax are the most common complications observed (13). Percutaneous Trans-splenic The trans-splenic approach is less injurious to the transplanted liver graft and is recommended in pediatric patients because of the upper location of the graft in the left subphrenic region (14). It is performed by puncturing the splenic vein with a 21-gauge Chiba needle (Cook, Bloomington, IN) under ultrasonographic and fluoroscopic guidance. The needle was changed to a 4-French coaxial dilator and a 7-French sheath (Terumo, Tokyo, Japan) over a 0.035-inch angled hydrophilic guide wire (Terumo) after confirmation that the needle was in the splenic vein. Direct main portal venography and the pressure gradient across the stenosis were then obtained. Engorgement of intraparenchymal hepatic artery with prominent Doppler ultrasound (DUS) arterial flow is usually seen in poor portal flow patients, especially in those with complete PV vein occlusion. A small-sized PV with no flow visualization is difficult to approach and may need several attempts to puncture. In this situation, parenchymal HA pseudoaneurysm can be the complication in pediatric LT during PV intervention (15). In our study, if the transhepatic approach is difficult to perform and is disadvantageous, the trans-splenic approach may be an alternative method. Transjugular In selecting the route to access the PV, bleeding tendency or massive ascites is considered a relative contraindication to the transhepatic or trans-splenic approaches (16). Although the transjugular approach is suitable for conditions where bleeding tendency or massive ascites is present, it is difficult to puncture the PV through this approach
Chen et al.
S33
especially in cases of total PV occlusion. Furthermore, the spatial relation between the hepatic vein and the PV after LT is another factor to consider especially in those who received a left lobe graft. Intraoperative PV Access The intraoperative portal vein stent placement is another method for managing patients with portal vein abnormalities. After reperfusion, when insufficient portal flow was detected by DUS, direct portogram can be performed and stent can be placed as an alternative procedure when surgical intervention failed. We report two cases in which this procedure was used to guide intraoperative PV stent placement through the inferior mesenteric vein approach using of the stump of the segment 4 PV in pediatric living donor liver transplant recipients (17).
COMPLICATIONS Hemoperitoneum and hemothorax are common complications in percutaneous transhepatic portal venous angioplasty and stenting (13). The trans-splenic approach is less injurious to the transplanted liver graft and is recommended in pediatric patients. A procedure-related complication occurred in 1 patient who had rupture of the splenic vein after puncturing with some contrast media extravasation. Immediate stenting was performed to relieve the high portal pressure. No further surgical intervention was required. This patient recovered one week later with no hemoperitoneum. The trans-splenic approach may be an alternative approach. Familiarity with the technique of vascular puncture under ultrasound-guidance is necessary for the procedure. Gentle and delicate manipulation of the puncture needle and guide wire advancement through the engorged thin-walled splenic vein is important.
FOLLOW-UP After stent placement, intravenous anticoagulation agent was given for 7 days to maintain an international normalized ratio of 1.5Y2.0. Oral antiplatelet overlapping with antiplatelets (aspirin 100 mg/day and/or dipyridamole 75 mg/day) and was given for 6 months. In patients with coagulopathy, oral antiplatelet was started only when their coagulation function had normalized. Good patency rate (100%) with self-expandable metallic stents was noted in long-term follow-up. A stented PV is not expected to increase in size as in a native PV, and a relative PV stenosis may occur in adult life. However, we are confident that a 7-mm size PV is able to supply sufficient amount for portal flow even in adults.
CONCLUSION In conclusion, portal vein stent placement is an effective and long-lasting treatment modality in treating of the portal venous occlusion. Early detection and diagnosis is essential for curative effect of stent placement and early treatment can achieve an excellent successful rate. Planning the best route to enter the portal venous system in deploying of the vascular stent is essential for yielding a safe and successful outcome.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S34
www.transplantjournal.com
Transplantation
& Volume 97, Number 8S, April 27, 2014
REFERENCES 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Fan ST, Lo CM, Liu CL. Experience of donor right lobe hepatectomy in adult-to-adult live donor liver transplantation: clinical analysis of 89 cases. Hepatobiliary Pancreat Dis Int 2002; 1: 166. Duffy JP, Hong JC, Farmer DG, et al. Vascular complications of orthotopic liver transplantation: experience in more than 4,200 patients. J Am Coll Surg 2009; 208: 896. Millis JM, Seaman DS, Piper JB, et al. Portal vein thrombosis and stenosis in pediatric liver transplantation. Transplantation 1996; 62: 748. Lerut J, Tzakis AG, Bron K, et al. Complications of venous reconstruction in human orthotopic liver transplantation. Ann Surg 1987; 205: 404. Ueda M, Oike F, Kasahara M, et al. Portal vein complications in pediatric living donor liver transplantation using left-side grafts. Am J Transplant 2008; 8: 2097. Unsinn KM, Freund MC, et al. Spectrum of imaging findings after pediatric liver transplantation: part 2, posttransplantation complications. Am J Roentgenol 2003; 181: 1139. Lo´pez Santamarı´a M, Ga´mez M, Murcia J, et al. Pre-hepatic portal hypertension as a late complication of liver transplantation in children. Cir Pediatr 2001; 14: 135. Chardot C, Herrera JM, Debray D, et al. Portal vein complications after liver transplantation for biliary atresia. Liver Transplant Surg 1997; 3: 351. Lucianetti A, Guizzetti M, Bertani A, et al. Liver transplantation in children weighing less than 6 kg. The Bergamo experience. Transplant Proc 2005; 37: 1143. Huang TL, Cheng YF, Chen TY, et al. Doppler ultrasound evaluation of postoperative portal vein stenosis in adult living donor liver transplantation. Transplant Proc 2010; 42: 879. Ou HY, Concejero AM, Huang TL, et al. Portal vein thrombosis in biliary atresia patients after living donor liver transplantation. Surgery 2011; 149: 40. Cheng YF, Ou HY, Tsang LL, et al. Vascular stents in the management of portal venous complications in living donor liver transplantation. Am J Transplant 2010; 10: 1276. Ko GY, Sung KB, Yoon HK, et al. Early posttransplantation portal vein stenosis following living donor liver transplantation: percutaneous transhepatic primary stent placement. Liver Transpl 2007; 13: 530. Cheng YF, Ou HY, Tsang LL, et al. Interventional percutaneous trans-splenic approach in the management of portal venous occlusion after living donor liver transplantation. Liver Transpl 2009; 15: 1378. Seu P, Shackleton C, Shaked A, et al. Improved results of the liver transplantation in patients with portal vein thrombosis. Arch Surg 1996; 131: 840. Otto G, Richter GM, Theilmann L, et al. [Liver transplantation after trans-jugular intrahepatic portosystemic stent shunt]. Chirurg 1992; 63: 730. Chen CL, Concejero AM, Ou HY, et al. Intraoperative portal vein stent placement in pediatric living donor liver transplantation. J Vasc Interv Radiol 2012; 23: 724.
SECTION 9. TECHNICAL DETAILS OF MICROSURGICAL BILIARY RECONSTRUCTION IN LIVING DONOR LIVER TRANSPLANTATION
Tsan-Shiun Lin,1 Chao-Long Chen,1,3 Allan M Concejero,1 Anthony Q. Yap,1 Yu-Hung Lin,1 Chun-Yi Liu,1 Yuan-Cheng Chiang,1 Chih-Chi Wang,1 Shih-Ho Wang,1 Chih-Che Lin,1 Chee-Chien Yong,1 and Yu-Fan Cheng2
Abstract. Small size and multiple ducts, particularly in right lobe liver grafts, are major factors that contribute to biliary complications in living donor liver transplantation. To improve the outcome of biliary reconstruction, further investigation and refinement of reconstruction techniques and management strategies are necessary. From March 2006 to June 2012, routine MBR was performed in 584 grafts in 581 consecutive LDLT (including 3 dual graft transplants). All biliary reconstructions were performed using microsurgical technique by a single microsurgeon. The classification of biliary reconstruction was based according to the number of ducts in the graft, the manner in which these ducts were reconstructed (with or without ductoplasty), and the conduit used (recipient duct or jejunum) to reconstruct the biliary tree. In ductto-duct reconstruction, posterior wall first technique by using interrupted suture and continuous running and interrupted tie technique (combined method) for the anterior wall were performed. Recipient reduction ductoplasty was done, if necessary. In duct-to-jejunum reconstruction, enterotomy was performed first under microscope; then, the serosal and mucosal layers were sutured together using 8-0 prolene to facilitate the anastomosis. Posterior wall first by using interrupted suture technique and combined method for the anterior wall were also performed. Overall, there were 397 right and 184 left lobe grafts. Single duct opening was noted in 440 (75.34%), two duct openings in 135(23.12%), and three duct openings in 9 (1.54%) grafts. Ductto-duct anastomosis was performed in 473 (81%) and duct-tojejunum Roux limb in 111 (19%) biliary reconstructions. Size discrepancy in the graft and recipient ducts was noted in 394 (83.3%) reconstructions. The overall biliary complication was 7.9%. These included 19 (3.3%) bile leaks and 27 (4.6%) biliary strictures. The routine use of MBR capably surmounts the difficulties brought about by the anatomic variations and the size discrepancies between the graft and recipient hepatic ducts with excellent outcome. Keywords: Biliary reconstruction, Microsurgical technique, Living donor liver transplantation, Biliary complications, Biliary outcome.
iliary complications (BC) following LDLT have remained high at a rate of 16% to 67% (1Y10). Small size and multiple ducts, particularly in the right lobe liver grafts are the major factors of such results (4). To overcome these complexities brought by anatomic variations, our institution has routinely used microsurgical biliary reconstruction (MBR) in LDLT since 2006 (11). At the onset of applying the MBR technique, recipient reduction ductoplasty was performed by a liver transplant surgeon without the aid of an operating microscope; then, the anastomosis was performed by the microsurgeon under an operating microscope with a magnification of 5 to 15. This practice resulted in an unacceptably high rate of BC (46.7%) in
B
This work was presented in the video session during the 2013 Asian summit on living donor liver transplantation held in Kaohsiung, Taiwan, January 12, 2013. The authors declare no funding or conflicts of interest. 1 Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. 2 Liver Transplantation Program and Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. 3 Address correspondence to: Chao-Long Chen, M.D., Liver Transplantation Program, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Sung, Kaohsiung, 83305 Taiwan. E-mail: [email protected]
Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0041-1337/14/9708-00 DOI: 10.1097/TP.0000000000000060
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
