Crucial Issues of Hepatic Artery Reconstruction in Living Donor Liver Transplantation: Our Experience with 133 Cases at Dar El-Fouad Hospital, Egypt

Abstract

Hepatic artery (HA) reconstruction is a crucial step in living donor liver transplantation (LDLT). However, many important aspects specific to this challenging step are still inadequately documented. From August 2001 through March 2007, we performed a total of 133 cases of LDLT at Dar El-Fouad Hospital. The magnifying loupe was used for performing microanastomoses in the first 31 cases, and the operating microscope was used for 98 cases. There were 128 adult and five pediatric patients. One hundred twenty-five patients received right lobe grafts, and seven patients received left lobe grafts. One patient died intraoperatively and was excluded from analysis. Arterial complications occurred in four patients of the first group (4/30, 13%) in the form of early thrombosis. One patient underwent successful interventional thromboembolectomy, two patients underwent surgical reexploration with revision of anastomoses; these three patients survived. The fourth patient died from fulminant liver failure. Regarding the second group, all arterial anastomoses were patent after reconstruction. Signal problems occurred in the form of intraoperative intermittent flow and postoperative no diastole phenomenon. Our overall arterial complication rate was 4.5%; however, we lost only one patient due to HA thrombosis (0.8%). Microsurgical reconstruction of the HA carries its own challenges. The use of operating microscope reduces the risk of complications, and aggressive interference including salvage surgery maximizes the success of HA reconstruction.

Untitled

“…The clinical insignificance of this high resistance flow had also been demonstrated in several reports. 4,[18][19][20] Our results agree with the HA buffer response theory in which the HA shows compensatory vasoconstriction reducing the arterial blood flow in response to portal hyperperfusion, thus leading to a high RI. 21,22 This phenomenon had been demonstrated intraoperatively by temporary clamping of the PV, which resulted in improved HA flow.…”

“…21,22 This phenomenon had been demonstrated intraoperatively by temporary clamping of the PV, which resulted in improved HA flow. 19 Other theories have related the early and transient elevation of the HA RI after DDLT to the older donor grafts, prolonged period of cold ischemia and preservation injury, graft steatosis, and chronic cholestatic disease as an indication for trans plant. 18,20,23 In addition, a decreased HA RI (< 0.50) can also be observed in the early postoperative period, although it was less common than a high HA RI.…”

Surgical rationalization of living donor liver transplantation by abolition of hepatic artery reconstruction under a fixed microscope

“…As most early HAT was reported to occur around a week after transplantation, early HAT in our series was defined as optimal recognition of thrombosis two wk after LDLT . The mortality rates of early HAT are reported to be between 11% and 56%, with a re‐transplantation rate as high as 83% . Warner et al.…”

Untitled

“…11 The use of magnification microscopes with continuous zoom and high magnification loupes reduces the incidence. 12 The complication HAS is a risk factor for HAT and should be corrected when detected during routine duplex ultrasonography surveillance. 7 Complications related to the portal vein are less common than those of the hepatic artery but are associated with high graft loss incidence.…”