Air Embolism Associated with Veno-venous Bypass during Orthotopic Liver Transplantation

Khoury, G. F.; Mann, Martin E.; Porot, M; Abdul-Rasool, Imad H.; Busuttil, Ronald W.

doi:10.1097/00000542-198711000-00048

Cited by 88 publications

(43 citation statements)

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“…4,20 However, venovenous bypass is time consuming, and specific drawbacks have been reported. 5,6 The piggyback technique has many advantages over the traditional technique. First, it does not require dissection of the retrocaval compartment, thus reducing retroperitoneal blood loss.…”

Section: Discussionmentioning

confidence: 99%

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Temporary portocaval shunt during liver transplantation with vena cava preservation. Results of a prospective randomized study

Figueras

2001

Liver Transplantation

108

114

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This study aims to determine whether the use of a temporary portocaval shunt (PCS) improves hemodynamic and metabolic evolution during orthotopic liver transplantation (OLT). Preservation of the vena cava during OLT has gained wide acceptance. However, benefits of adding a temporary PCS to the piggyback technique during the anhepatic phase in patients with cirrhosis have not been shown. Eighty patients with cirrhosis were studied prospectively. They were randomly distributed into two groups: patients with a temporary PCS (n ‫؍‬ 40) and those without a PCS (n ‫؍‬ 40). In all cases, the piggyback technique was used. Hemodynamic profiles and biochemical data during OLT and clinical evolution after OLT were evaluated. Preoperative data were similar in both groups. Surgical time also was similar (403 ؎ 77 v 387 ؎ 56 minutes; P ‫؍‬ .3). Red blood cell requirements were lower in the PCS group (2.3 ؎ 2.5 v 3.3 ؎ 2.9 units), although differences were not significant. In the PCS group, 45% of patients did not need red blood cell transfusion, whereas in the other group, only 22% were not administered a transfusion (P ‫؍‬ .03). During the anhepatic phase, the decrease in cardiac output was lower in the PCS group (-9.6% v -19%; P ‫؍‬ .05), whereas diuresis during the anhepatic phase was greater in the PCS group (3.6 ؎ 2.97 v 2.1 ؎ 1.38 mL/kg/h; P ‫؍‬ .005). There were no differences in liver biochemical parameters during the first 3 postoperative days. Nevertheless, creatinine levels increased significantly during this period only in the no-PCS group. The use of a temporary PCS during OLT improves hemodynamic status, reduces intraoperative transfusion requirements, and preserves renal function during and after OLT. T he classic surgical technique for orthotopic liver transplantation (OLT) involves recipient hepatectomy with resection of the retrohepatic vena cava and cross-clamping of the portal vein. 1 Interruption of caval flow during the anhepatic phase results in a reduction in venous return to the heart 2 and a decrease in renal perfusion, 3 as well as splanchnic hyperemia secondary to portal clamping. Venovenous bypass improves hemodynamic stability and allows decompression of the occluded splanchnic venous system. 4 However, the use of venous bypass is associated with other complications, such as hypothermia and pulmonary thromboembolism. 5,6 In 1968, Calne and Williams 7 described preservation of the vena cava. This technique, known as piggyback, 8 was further developed in pediatric OLT, 9 but has gained wide acceptance in adults, mainly in Europe. [10][11][12][13] Nevertheless, it does not avoid splanchnic hyperemia secondary to portal clamping.The use of a temporary portocaval shunt (PCS) with the piggyback technique was first described by Tzakis et al,14 then by Belghiti at al. 15 Previous studies have shown that preservation of both portal and caval blood flows throughout the procedure maintains hemodynamic stability and renal perfusion pressure. [16][17][18][19] This technique is particularly useful for patient...

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Section: Discussionmentioning

confidence: 99%

“…4 However, the use of venous bypass is associated with other complications, such as hypothermia and pulmonary thromboembolism. 5,6 In 1968, Calne and Williams 7 described preservation of the vena cava. This technique, known as piggyback, 8 was further developed in pediatric OLT, 9 but has gained wide acceptance in adults, mainly in Europe.…”

mentioning

confidence: 99%

Temporary portocaval shunt during liver transplantation with vena cava preservation. Results of a prospective randomized study

Figueras

2001

Liver Transplantation

108

114

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“…The routine use of a VVB 10 limits the hemodynamic disorders induced by clamping but has its iatrogenic risks, including thromboembolic accidents, air embolism, and infectious complications. 11,12 Moreover, its systematic use has recently been questioned with regard to the improvement of intraoperative management. 13 Preservation of the IVC was a first step of surgical advance in this area.…”

Section: Discussionmentioning

confidence: 99%

Orthotopic liver transplantation with preservation of portocaval flow compared with venovenous bypass

et al. 1997

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Conventional liver transplantation requires crossclamping of the hepatic pedicle and inferior vena cava, leading to severe hemodynamic and metabolic disturbances, usually attenuated by the use of venovenous bypass. A more recent surgical technique, piggyback with temporary portocaval shunting, preserves both caval and portal blood flows. The aim of this study was to compare the two methods prospectively. Forty-four patients with chronic liver disease were studied. Local anatomic conditions guided the surgeon to choose the easiest way to remove the native liver. Anesthetic management was standardized. Hemodynamic and metabolic changes were assessed by use of routine tests at specific periods. Graft function was evaluated by measurement of aminotransferases and monoethylglycinexylidide (MEGX) test 12, 24, 48, and 72 hours postoperatively. Conventional liver transplantation with venovenous bypass was performed in 26 patients, and the piggyback with temporary portocaval shunting was performed in 15 patients. ANOVA showed that cardiac output and systemic oxygen delivery were better maintained before revascularization in the piggyback group. Metabolic changes were comparable, and hyperfibrinolytic activity was detected in both groups. Graft function was comparable and satisfactory within the 3 first postoperative days. Piggyback with temporary portocaval shunting provided better intraoperative hemodynamics and tissue oxygenation than liver transplantation with venovenous bypass.

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“…The aim of this technique is to reduce hemodynamic instability, ensure splanchnic decompression, and minimize venous hypertension and intestinal edema (14). However, the ex situ ex vivo procedure is associated with complications, including air embolism, thromboembolic events and mechanical injury due to global capillary leak, which can lead to severe post-operative water, electrolyte and acid-base imbalances (15). Thus, the present study used a vascular prosthesis to reconstitute blood flow in the portal vein and IVC to ensure the stability of general circulation, lessen ischemia-reperfusion injury, and avoid acid-alkali and electrolyte imbalances.…”

Section: Discussionmentioning

confidence: 99%

Ex vivo hepatectomy and partial liver autotransplantation for hepatoid adenocarcinoma: A case report

et al. 2015

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Abstract.We previously reported the case of a 56-year-old male who underwent surgical treatment for gastric hepatoid adenocarcinoma and splenic metastasis. The present study reports the case of the same patient who underwent successful ex vivo hepatectomy and partial liver autotransplantation. Computed tomography scans demonstrated that the tumor was located in the left and caudate lobes of the liver, with hepatic vein and inferior vena cava involvement, and right portal vein compression. To clarify the association between the vessels and the tumor, a three-dimensional imaging technique was used to reconstruct the liver architecture. During the surgery, the whole liver was removed with the retrohepatic vena cava, which was replaced with a prosthetic graft without a veno-venous bypass; a portacaval shunt for the anhepatic phase was performed simultaneously. The surgery lasted 9 h, and the anhepatic phase lasted 4 h. Blood loss during the surgery was recorded at 1,500 ml. The time taken for recovery was 21 days post-surgery, and at 20 months, the patient was disease-free. To the best of our knowledge, this is the first case of ex vivo liver resection performed for hepatic metastasis of hepatoid adenocarcinoma to be reported.

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Air Embolism Associated with Veno-venous Bypass during Orthotopic Liver Transplantation

Cited by 88 publications

References 0 publications

Temporary portocaval shunt during liver transplantation with vena cava preservation. Results of a prospective randomized study

Temporary portocaval shunt during liver transplantation with vena cava preservation. Results of a prospective randomized study

Orthotopic liver transplantation with preservation of portocaval flow compared with venovenous bypass

Ex vivo hepatectomy and partial liver autotransplantation for hepatoid adenocarcinoma: A case report

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