Impact of Temporary Portocaval Shunting and Initial Arterial Reperfusion in Orthotopic Liver Transplantation

Abstract

The use of a temporary portocaval shunt (TPCS) as well as the order of reperfusion (initial arterial reperfusion [IAR] versus initial portal reperfusion) in orthotopic liver transplantation (OLT) is controversial and, therefore, still under debate. The aim of this study was to evaluate outcome for the 4 possible combinations (temporary portocaval shunt with initial arterial reperfusion [A+S+], temporary portocaval shunt with initial portal reperfusion, no temporary portocaval shunt with initial arterial reperfusion, and no temporary portocaval shunt with initial portal reperfusion) in a center‐based cohort study, including liver transplantations (LTs) from both donation after brain death and donation after circulatory death (DCD) donors. The primary outcome was the perioperative transfusion of red blood cells (RBCs), and the secondary outcomes were operative time and patient and graft survival. Between January 2005 and May 2017, all first OLTs performed in our institution were included in the 4 groups mentioned. With IAR and TPCS, a significantly lower perioperative transfusion of RBCs was seen (P < 0.001) as well as a higher number of recipients without any transfusion of RBCs (P < 0.001). A multivariate analysis showed laboratory Model for End‐Stage Liver Disease (MELD) score (P < 0.001) and IAR (P = 0.01) to be independent determinants of the transfusion of RBCs. When comparing all groups, no statistical difference was seen in operative time or in 1‐year patient and graft survival rates despite more LTs with a liver from a DCD donor in the A+S+ group (P = 0.005). In conclusion, next to a lower laboratory MELD score, the use of IAR leads to a significantly lower need for perioperative blood transfusion. There was no significant interaction between IAR and TPCS. Furthermore, the use of a TPCS and/or IAR does not lead to increased operative time and is therefore a reasonable alternative surgical strategy.

Portocaval shunt and its Implications for Liver Transplantation: An Integrative Literature Review

“…Portal vein clamping during the procedure was associated with increased intestinal edema and bacterial translocation. 1,3,7,14 Despite the pathophysiology described in several studies, only one study investigated whether the described translocation resulted in an increase in postoperative infection, comparing groups with TPCS and use of meropenem, TPCS and use of meropenem plus vancomycin and the group without TPCS. 18 The hypothesis, however, proved to be null, with no difference between the three groups in terms of the general incidence of infections and gram-negative infections, with only a tendency towards greater gram-positive infections in the TPCS and use of meropenem.…”

“…1) and increase portal hypertension, which leads to intestinal edema and mucosal barrier dysfunction, with bacterial translocation, endotoxemia and secretion of inflammatory mediators. [1][2][3] After declamping the portal vein, these factors are released into the circulation, which can cause systemic vasodilation, hypotension, and ischemia-reperfusion syndrome and, eventually, primary graft dysfunction. 2,3 Inferior Vena Cava Left Gastric Vein Splenic Vein Therefore, early in the history of transplantation, the technique of venous bypass was developed to avoid splanchnic and systemic venous congestion and other deleterious effects caused by clamping the portal vein during the anhepatic phase.…”

“…10,12 Despite this, the benefits of TPCS remain controversial, with studies showing conflicting results. 1,3,14,15 The objective of this review, therefore, was to analyze the literature found in the databases on TPCS and THPCS in liver transplantation in adults.…”

Shunt Portocava y sus Implicaciones para el Transplante de Hígado: Una Revisión Integrativa de la Literatura

“…10,12 A pesar de esto, los beneficios del SPCT permanecen controvertidos, con trabajos mostrando resultados conflictivos. 1,3,14,15 El objetivo de esta revisión, por tanto, fue hacer un análisis de la literatura encontrada en las bases de datos sobre SPCT y SHPCT en el transplante hepático en adultos.…”

“…1) y aumentar la hipertensión portal, lo que lleva al edema intestinal y a la disfunción de la barrera de la mucosa, con translocación bacteriana, endotoxemia y secreción de mediadores inflamatorios. [1][2][3] Después de desclampear la vena porta, estos factores son liberados en la circulación, pudiendo provocar vasodilatación sistémica, hipotensión y síndrome de la isquemia-reperfusión y, eventualmente, disfunción primaria del injerto. 2,3 Vena Cava Inferior Vena Gástrica Izquierda…”