Choice of Surgical Technique Influences Perioperative Outcomes in Liver Transplantation

Shokouh-Amiri, Hosein; Gaber, A. Osama; Bagous, Wagdy A.; Grewal, Hani P.; Hathaway, Donna; Vera, Santiago; Stratta, Robert J.; Bagous, T.; Kizilisik, Tarik

doi:10.1097/00000658-200006000-00005

Cited by 84 publications

(59 citation statements)

References 21 publications

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“…However, such difficulties also were more frequent in patients with cholestatic liver diseases, a finding in line with previous studies reporting the potential complexity of dissecting the liver of the retrohepatic IVC in these patients. 11 Similarly, this series confirms that liver resection was more difficult after preoperative arterial chemoembolization as a result of perihepatic adhesions between the liver parenchyma and IVC. 16 Nevertheless, it must be emphasized that even if the proportion of patients requiring transient IVC cross-clamping during hepatectomy approached 10%, this transient clamping was well tolerated.…”

Section: Discussionsupporting

confidence: 74%

“…In particular, these advantages include shorter warm ischemia and duration of surgery, 6,10-12 improved intraoperative hemodynamic stability, 9,10 improved tissue oxygen delivery, 9 preservation of renal perfusion pressure, improved postoperative renal function, 6,10 and significant cost savings. 11 Therefore, caval preservation has gained increased acceptance, especially in Europe, where recent surveys showed it is used more commonly than the conventional technique. 3,13 Despite the widespread use of IVC preservation during OLT, controversy remains about its feasibility and potential contraindications.…”

Section: Discussionmentioning

confidence: 99%

“…This relatively high incidence could result from the extension of IVC preservation to patients who usually undergo the conventional transplantation technique without IVC preservation. 6,11,13 It is not surprising that difficulties leading to transient IVC cross-clamping during hepatectomy were more frequently encountered in patients with large livers, i.e., those with BuddChiari syndrome and polycystic liver disease. However, such difficulties also were more frequent in patients with cholestatic liver diseases, a finding in line with previous studies reporting the potential complexity of dissecting the liver of the retrohepatic IVC in these patients.…”

Section: Discussionmentioning

confidence: 99%

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Feasibility and limits of caval-flow preservation during liver transplantation

Belghiti

2001

Liver Transplantation

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As promoters of orthotopic liver transplantation (OLT) with preservation of caval flow, we reviewed our 8-year experience to assess the feasibility and limits of this technique. Preservation of caval flow during OLT, which improves intraoperative hemodynamic stability, was not considered feasible in a significant proportion of transplant recipients. When transient clamping of caval flow is required, causes and consequences of this clamping during all phases of the procedure were not reported. Between 1991 and 1998, a total of 275 OLTs using a whole graft were performed in 259 patients with a policy consisting of a systematic attempt to preserve inferior vena cava ( P reservation of the inferior vena cava (IVC) during orthotopic liver transplantation (OLT), described by Calne and William 1 in 1968, was popularized in 1989 by Tzakis et al 2 as the piggyback procedure. It was advocated that the main advantages of this procedure were to avoid retrocaval dissection to reduce the risk for bleeding and facilitate caval anastomosis in patients receiving large-for-size grafts. 2,3 As originally described, this procedure was frequently performed using transient cross-clamping of the IVC, especially in the case of difficulty disconnecting the native liver from the retrohepatic IVC. 2 As a consequence, this procedure was frequently performed in conjunction with venovenous bypass, with the aim to overcome the hemodynamic consequences of IVC cross-clamping. 2 To avoid the need for venovenous bypass, we described in 1992 a modification of the piggyback technique in which caval flow was preserved throughout the OLT procedure. 4 This modification made preservation of IVC blood flow possible by performing either a sideto-side or end-to-side cavocaval anastomosis and using the middle and left hepatic cuff with partial IVC clamping at its anterior face. 5 In addition, splanchnic venous drainage could be maintained through a transient portocaval anastomosis. 5 Although this procedure was shown to help improve intraoperative hemodynamic stability, several investigators objected that it was not feasible in a significant proportion of transplant recipients. [6][7][8][9] Since 1991, we have attempted systematically to use the modified piggyback technique for all OLTs at our center. As promoters of this technique, we review our experience over the ensuing 8 years in an attempt to determine the feasibility of caval-flow preservation and report the rate, causes, and consequences of total IVC clamping.

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Section: Discussionsupporting

confidence: 74%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Feasibility and limits of caval-flow preservation during liver transplantation

Belghiti

2001

Liver Transplantation

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“…In a patient with cirrhotic cardiomyopathy the use of caval preservation techniques (piggyback), or the addition of veno-venous bypass if caval cross clamp is employed, will minimise the large variations in preload with the maintenance of caval flow during explantation [78,79] . This would decrease the reliance on positive chronotropy to maintain cardiac output in the face of reduced venous return, a compensation mechanism that may be impaired in CCM.…”

Section: Maintaining Preload and Fluid Managementmentioning

confidence: 99%

Cirrhotic cardiomyopathy: Implications for the perioperative management of liver transplant patients

Rahman

Mallett

2015

WJH

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Cirrhotic cardiomyopathy is a disease that has only recently been recognised as a definitive clinical entity. In the setting of liver cirrhosis, it is characterized by a blunted inotropic and chronotropic response to stress, impaired diastolic relaxation of the myocardium and prolongation of the QT interval in the absence of other known cardiac disease. A key pathological feature is the persistent over-activation of the sympathetic nervous system in cirrhosis, which leads to down-regulation and dysfunction of the β-adrenergic receptor. Diagnosis can be made using a combination of echocardiography (resting and stress), tissue Doppler imaging, cardiac magnetic resonance imaging, 12-lead electrocardiogram and measurement of biomarkers. There are significant implications of cirrhotic cardiomyopathy in a number of clinical situations in which there is an increased physiological demand, which can lead to acute cardiac decompensation and heart failure. Prior to transplantation there is an increased risk of hepatorenal syndrome, cardiac failure following transjugular intrahepatic portosystemic shunt insertion and increased risk of arrhythmias during acute gastrointestinal bleeding. Liver transplantation presents the greatest physiological challenge with a further risk of acute cardiac decompensation. Peri-operative management should involve appropriate choice of graft and minimization of large fluctuations in preload and afterload. The avoidance of cardiac failure during this period has important prognostic implications, as there is evidence to suggest a long-term resolution of the abnormalities in cirrhotic cardiomyopathy. Core tip: Cirrhotic cardiomyopathy is characterised by a blunted inotropic and chronotropic response to stress, impaired diastolic relaxation and prolongation of the QT interval. It is only recently that it has been recognised as a definitive clinical entity, and yet it has significant implications in a number of clinical situations in which there is increased physiological demand, which can lead to acute cardiac decompensation and heart failure. Liver transplantation is one such situation, and in this review we discuss criteria for diagnosis, possible methods to limit further deterioration and the perioperative management of these patients.

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“…However, using the piggyback technique remains the splanchnic congestion that may influence the severity of reperfusion syndrome (cardiovascular collapse after the "new" liver in the recipient's blood rich in substances like potassium, cytokines , peroxide radicals, among others) and complicating the evolution of graft. To avoid congestion in the splanchnic piggyback can be used to temporary portacaval shunt 25 . In the piggyback technique with or without portacaval shunt, surgical time increases and can compromise the results of TxF.…”

Section: Advantages and Disadvantages Of Dvvmentioning

confidence: 99%

Transplante de fígado clínico sem desvio venovenoso

Fonseca-Neto¹

2011

ABCD, arq. bras. cir. dig.

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-Introduction -The use of a venovenous bypass in liver transplantation is a controversy source and discussion among anesthetists and transplant surgeons.Although it provides a stable hemodynamic state and metabolism during the anhepatic stage, venovenous bypass may lead to a number of complications, some of them with death. Aim -To review the current practice of using clinic venovenous bypass in liver transplantation, with its advantages and disadvantages. Method -A broad review of the literature was carried out, paying especial attention to articles published in the past ten years and indexed in PubMed and Medline. The following cross-referenced headings were used: liver transplantation, venovenous bypass, conventional technique, classic technique. The articles chosen for analysis were those of the greatest relevance and those considered "classics" in the subject. Conclusion -Liver transplantation without venovenous bypass is a safe and rapid technique. In most cases it can be used without giving rise to serious complications in patients with liver disease. ABCDDV/783RESUMO -Introdução -O problema da utilização do desvio venovenoso no transplante de fígado é um ponto de discussão e controvérsia entre anestesistas e cirurgiões transplantadores. Apesar de proporcionar ambiente hemometabólico estável durante a fase anepática o seu uso poderá levar a algumas complicações, inclusive fatais. Objetivo -Revisar a prática atual do uso do desvio venovenoso no transplante de fígado clínico, com suas vantagens e desvantagens. Método -Foi realizada ampla pesquisa na literatura, com especial atenção aos artigos publicados nos últimos 10 anos e indexados ao PubMed e Medline. Foram utilizados os seguintes descritores de forma cruzada: liver transplantation, venovenous bypass, conventional technique, classic technique. Entre os artigos encontrados foram considerados para análise os mais relevantes além dos considerados "clássicos" sobre o assunto. Conclusão -Transplante de fígado sem desvio venovenoso é técnica segura e rápida. Pode ser utilizada, com poucas exceções, sem acarretar complicações maiores nos pacientes com doença hepática.

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Choice of Surgical Technique Influences Perioperative Outcomes in Liver Transplantation

Cited by 84 publications

References 21 publications

Feasibility and limits of caval-flow preservation during liver transplantation

Feasibility and limits of caval-flow preservation during liver transplantation

Cirrhotic cardiomyopathy: Implications for the perioperative management of liver transplant patients

Transplante de fígado clínico sem desvio venovenoso

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