Recipient hepatectomy with preservation of inferior vena cava reduces the need for veno-venous bypass in liver transplantation

Margarit, C; Lázaro, José; Balsells, J.; Charco, Ramón; Murio, E.; Edo, Ayaka; Gifre, E.

doi:10.1111/j.1432-2277.1994.tb01335.x

Cited by 25 publications

(19 citation statements)

References 3 publications

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“…Different studies in CLTx have shown that the main proposed indications for using VVB are hemodynamic instability following test clamping of the IVC, impaired cardiac and renal function, fulminant hepatic failure (FHF), severe portal, massive bleeding during hepatectomy due to severe portal hypertension, and in cases with familial amyloidotic polyneuropathy during hepatectomy 15 27 31–37 . Proposed indications and their presumed pros and cons for the use of VVB are summarized in Table I, and claimed advantages and disadvantages of its use by different authors in Table II 15 27 31–37 .…”

Section: Venovenous Bypass In Cltxmentioning

confidence: 99%

The need for venovenous bypass in liver transplantation

Fonouni

Mehrabi

Soleimani

et al. 2008

HPB

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Since introduction of the conventional liver transplantation (CLTx) by Starzl, which was based on the resection of recipient inferior vena cava (IVC) along the liver, the procedure has undergone several refinements. Successful use of venovenous bypass (VVB) was first introduced by Shaw et al., although in recent decades there has been controversy regarding the routine use of VVB during CLTx. With development of piggyback liver transplantation (PLTx), the use of caval clamping and VVB is avoided, leading to fewer complications related to VVB. However, some authors still advocate VVB in PLTx. The great diversity among centers in their use of VVB during CLTx, or even along the PLTx technique, has led to confusion regarding the indication setting for VVB. For this reason, we present an overview of the use of VVB in CLTx, the target of patients for whom VVB could be beneficial, and the needs assessment of VVB for patients undergoing PLTx. Recent studies have shown that with the advancement of surgical skills, refinement of surgical techniques, and improvements in anesthesiology, there are only limited indications for doing CLTx with VVB routinely. PLTx with preservation of IVC can be performed in almost all primary transplants and in the majority of re-transplantations without the need for VVB. Nevertheless, in a few selective cases with severe intra-operative hemodynamic instability, or with a failed test of transient IVC occlusion, the application of VVB is still justifiable. These indications should be judged intra-operatively and the decision is based on each center's preference.

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Section: Venovenous Bypass In Cltxmentioning

confidence: 99%

The need for venovenous bypass in liver transplantation

Fonouni

Mehrabi

Soleimani

et al. 2008

HPB

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“…8 Recipient hepatectomy with preservation of the inferior vena cava and graft implantation with anastomosis of the donor suprahepatic inferior vena cava to a common channel of the three recipient hepatic veins was performed in both cases. Portal vein and hepatic artery anastomoses were performed before graft revascularization.…”

Section: Case Reportsmentioning

confidence: 99%

Liver transplantation in patients with splenorenal shunts: Intraoperative flow measurements to indicate shunt occlusion

et al. 1999

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Two patients with previous distal splenorenal shunts (DSRSs) performed 6 years earlier underwent liver transplantation (LT). A preoperative selective mesenteric artery angiogram showed collateral veins draining mesenteric venous flow into the shunt. Intraoperative flow measurements were performed to assess the steal of portal venous flow by the shunt and determine the need for shunt occlusion. Portal vein, hepatic artery, and shunt flows were measured by ultrasound transit-time flow probes in the native liver and after graft implantation with and without temporary shunt occlusion. Hemodynamic studies showed that long-standing DSRSs are high-flow shunts that steal portal flow. After graft implantation, DSRS flows remained high. Occlusion of the shunts produced an increase in portal vein flow at an amount similar to those of splenorenal shunt. Thus, the flow measurements showed persistent steal by the shunts after graft implantation and, therefore, the DSRSs were occluded but splenectomy was not performed. We conclude that the decision to occlude a DSRS should be based on the demonstration of steal of portal flow by the shunt and reversibility once the shunt is occluded. Splenectomy is not required when the DSRS is occluded. Copyright 1999 by the American Association for the Study of Liver DiseasesA distal splenorenal shunt (DSRS) 1 is used to treat recurrent bleeding from gastroesophageal varices in patients with good liver function after failure of sclerotherapy and pharmacological treatments. 2 The purpose of this shunt is to selectively decompress the variceal territory while portal perfusion to the liver is maintained, thus preventing encephalopathy and liver failure. 3,4 However, collateral veins gradually develop over time, producing a decrease in portal perfusion by leakage from the high-pressure mesenteric bed into the decompressed gastrosplenic bed, thereby converting the DSRS into a central or nonselective shunt. [5][6][7] Optimal portal venous flow is essential for successful liver grafting. Therefore, central portosystemic shunts should be closed after graft implantation to avoid diversion of portal flow from the graft. As far as a DSRS is concerned, controversy exists as to whether shunt occlusion is warranted.We present the intraoperative flow measurements performed in 2 patients with distal DSRSs during liver transplantation (LT) that permitted us to measure the steal of portal flow by the shunt and decide on the need for shunt occlusion. Case ReportsA 64-year-old woman and a 34-year-old man, both with hepatitis C viral cirrhosis and hepatocellular carcinoma, underwent LT. In both cases, a DSRS had been performed 75 months earlier and liver function was well preserved. The tumors were confirmed by fine-needle aspiration cytology. Selective celiac and mesenteric angiography were performed, followed by selective arterial chemoembolization with lipiodol, doxorubicin, and gelfoam. These angiographies showed a patent DSRS (Fig 1). The portal vein was patent, but with poor perfusion. Collateral pancreati...

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“…For the venous anastomosis the classical piggyback technique was used in all split‐liver transplantations (13), and the Belghiti technique with side‐to‐side cavo‐caval anastomosis in full organ transplantations (14). An extracorporal veno‐venous bypass was not necessary in any of the 34 transplantations.…”

Section: Methodsmentioning

confidence: 99%

A new pediatric liver transplantation program in Southern Germany. The Heidelberg experience

Engelmann

Schmidt

Weitz

et al. 2010

Pediatric Transplantation

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pLTx is a highly complex procedure. It can only be performed safely by experienced teams. Starting a new pLTx program in a country with established centers must therefore avoid a learning curve. We have initiated a liver transplantation program for children in 2003. Medical standards were defined by a team of surgeons, pediatricians, radiologists, anesthesiologists, and pathologists before the first transplantation. An external expert in the field of pLTx supervised the whole process. In a pilot phase, six children weighing more than 20 kg were successfully transplanted. Following this series, the clinical pathways were re-evaluated, and the program was opened for children of all age groups. Between 2003 and 2008, 32 children received 34 organs. Sixty-eight percent of patients received a split-liver, 26% a full size organ, and 6% a reduced size graft. Four LRLTx were performed. Patient survival rate was 91%. We conclude that a new pLTx program can be established without a significant learning curve regarding mortality if a strict strategy of team-building is followed. In the pilot phase, small children and infants have to be referred and transplanted in an established center. An interdisciplinary team of specialists closely working together is the key for sustained success.

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Recipient hepatectomy with preservation of inferior vena cava reduces the need for veno-venous bypass in liver transplantation

Cited by 25 publications

References 3 publications

The need for venovenous bypass in liver transplantation

The need for venovenous bypass in liver transplantation

Liver transplantation in patients with splenorenal shunts: Intraoperative flow measurements to indicate shunt occlusion

A new pediatric liver transplantation program in Southern Germany. The Heidelberg experience

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