Renal outcomes following left renal vein harvest for venous reconstruction during pancreas and liver surgery.

BACKGROUND: The left renal vein (LRV) may be used for venous reconstruction during hepato-pancreato-biliary (HPB) surgery, although concerns exist about compromising renal function. This study aimed to determine renal outcomes following LRV harvest during HPB resections. METHODS: Circumferential PV/SMV resections from 2008 to 2014 were included within two groups (LRV harvest, Control). Absolute and change in Creatinine (Cr) and estimated GFR (eGFR), and rates of acute kidney injury (AKI) and chronic kidney disease (CKD), were compared. Multivariate logistic regression analyses were performed. RESULTS: 76 patients were included (LRV n = 17, Control n = 59). Median Cr and eGFR did not change within groups, although change in eGFR differed between groups at postoperative day (POD) 3 (-4.3 vs. 12.8, p = 0.0035) and 7 (-1.8 vs. 12.4, p = 0.0074). AKI occurred more frequently in the LRV group at POD1 (5/17 vs. 4/59, p = 0.023) and POD3 (5/17 vs. 3/59, p = 0012), with no difference in CKD between groups (2/11 vs. 5/33 at 3 months, p = 0.99). LRV harvest was an independent risk factor for AKI at POD1 and POD3, but not thereafter. CONCLUSIONS: Patients who undergo LRV harvest experience a higher rate of AKI in the first three post-operative days. LRV harvest during pancreas resection does not impact on long-term renal function.

Living Related Renal Transplantation Using a Saphenous Vein Graft: A Case Report.

We report a case of living related renal transplantation that used the recipient's saphenous vein as a graft to extend the length of the right donor renal vein. A 41-year-old woman underwent ABO-incompatible living related renal transplantation from her 74-year-old mother in November 2014. A retroperitoneal laparoscopic right donor nephrectomy was performed, because the right kidney showed a cyst on preoperative computed tomography. As the right kidney after donor nephrectomy had a short renal vein and the kidney was large at 280 g, anastomosis with the external iliac vein was difficult. Therefore, we obtained the recipient's 15-cm-long right saphenous vein and created a 1 cm saphenous vein graft. We anastomosed 1 side of the saphenous vein graft to the allograft renal vein in bench surgery and performed end-to-side anastomosis of the other end to the recipient's external iliac vein. The allograft renal artery was used to perform end-to-end anastomosis to the recipient's internal iliac artery. Allograft kidney function was good after transplantation. When the longer axis of the renal graft vein is short, as in the right kidney, a saphenous vein graft may be useful.

Co-occurring superior mesenteric artery syndrome and nutcracker syndrome requiring Roux-en-Y duodenojejunostomy and left renal vein transposition: a case report and review of the literature.

BACKGROUND: The duodenum and the left renal vein occupy the vascular angle made by the superior mesenteric artery and the aorta. When the angle becomes too acute, compression of either structure can occur. Each type of compression is associated with specific clinical symptoms that constitute a rare disorder. If clinical symptoms are mild, conservative treatment is implemented. However, surgery is often the only solution that can improve quality of life and/or avoid life-threatening complications. This report describes a case of a patient with both types of aortomesenteric compression that required two separate surgeries to alleviate all symptoms. CASE PRESENTATION: A 20-year-old white woman presented to the Emergency Room complaining of sudden onset severe left flank and lower left quadrant abdominal pain, nausea, and vomiting. A clinical work-up revealed elevated white blood cells and hematuria. She was discharged with a diagnosis of urinary tract infection. Symptoms continued to worsen over the subsequent 2 months. Repeated and extensive clinical work-ups failed to suggest evidence of serious pathology. Ultimately, an endoscopy revealed obstruction of her duodenum, and barium swallow identified compression by the superior mesenteric artery, leading to the diagnosis of superior mesenteric artery syndrome. She underwent a Roux-en-Y duodenojejunostomy. Six weeks later she continued to have severe left-sided pain and intermittent hematuria. Venography revealed compression of the left renal vein, extensive pelvic varices, and significant engorgement of her left ovarian vein. A diagnosis of nutcracker syndrome was made and a left renal vein transposition was performed. Significant improvement was seen after 8 weeks. CONCLUSIONS: The disorders associated with aortomesenteric compression can lead to serious symptoms and sometimes death. Diagnosis is challenging not only because of the lack of awareness of these rare disorders, but also because they are associated with symptoms that are similar to those seen in less serious diseases. Guidance for health care professionals with respect to relevant radiological and clinical markers needs to be reconsidered in order to clarify the etiology of the diseases and create better diagnostic protocols.

Surgical Challenge in Pediatric Kidney Transplant Vascular Anastomosis.

During pediatric kidney transplant, surgical challenges occasionally occur. In particular, vascular anastomosis should be considered for children with small body weight < 12 kg, multiple renal arteries, vascular anomaly, and inferior vena cava occlusion. In pediatric patients, a living-donor renal graft is usually donated from a parent. Therefore, the renal artery and vein are too large to be anastomosed with the recipient's internal iliac artery and external iliac vein. In children who are > 12 kg, the renal artery and vein could be anastomosed with the external iliac artery and the external iliac vein. In children who are < 10 kg, the renal artery and vein should be anastomosed directly with the aorta and inferior vena cava. A pediatric transplant surgeon should consider arterial and venous anastomosis sites before transplant surgery. In small children with partial or total inferior vena cava occlusion, the venous anastomosis site should be evaluated. If the graft is placed on the left side, a venous graft must be used as a bridge between the renal vein and inferior vena cava. In 13 kidney transplants in children with inferior vena cava occlusion, 7 were on the left and 6 were on the right side. A patent segment of the inferior vena cava, the left original renal vein, an ascending lumbar vein, an azygos vein, the first graft renal vein, and a portal vein were used for venous anastomosis in 6, 2, 2, 1, 1 and 1 recipient, respectively. One child had graft loss due to renal vein thrombosis and one died of hemorrhage immediately posttransplant. Three had grafts with relatively long-term function, but these were lost due to chronic allograft nephropathy 100, 122, and 137 months posttransplant. However, the other 8 recipients have so far maintained graft function from 6 to 138 months since transplant.

Renal Function Preservation in Surgical Resection of Primary Inferior Vena Cava Leiomyosarcoma Involving the Renal Veins.

OBJECTIVE: This retrospective study aimed to show the practice of preserving renal function during curative resection of inferior vena cava leiomyosarcoma (IVCL) involving the renal veins at a single institution over a 7 year period. MATERIALS AND METHODS: From February 2009 to February 2017, 10 patients (6 women; median age 49 years) with IVCL involving the renal veins were treated surgically at Peking Union Medical College Hospital. En bloc resections were performed in all patients, and the renal outflows were preserved in eight patients using a new method: venoplasty of the renal ostia (VRO). Data regarding patient details, pre-operative preparation, surgical procedures, post-operative recovery, and follow-up results were obtained and reviewed retrospectively. RESULTS: Computed tomography and intra-operative examinations revealed that renal vein confluences were involved but not invaded in all cases except Patient 4. All patients underwent curative en bloc tumour excision; a right nephrectomy was performed in only one patient (Patient 4) whose tumour invaded the right renal vein. The mean operation time was 358 min and the mean blood loss 1935 mL. At a median follow-up of 54.5 months, the 5 year local recurrence, distant metastasis, overall survival, and disease-free survival rates were 20%, 10%, 68.6%, and 38.1%, respectively. CONCLUSIONS: Venoplasty of the renal ostia is an effective method of preserving the renal veins and reconstructing renal outflow.

Operative interventions for extrahepatic portomesenteric venous aneurysms and long-term outcomes.

BACKGROUND: Extrahepatic portal venous aneurysms (PVAs) are rare, and the pathogenesis is not fully understood. The optimum management of these patients is unknown. METHODS: Consecutive patients with PVA were identified over an 18-year period (1992-2010). A retrospective review was conducted. Clinical presentation, modality of diagnosis, surgical treatment, 30-day morbidity and mortality, and follow-up are reported. RESULTS: Four patients were identified who underwent surgical management of an extrahepatic PVA. Operative technique using left renal vein, femoral vein panel graft, polytetrafluoroethylene (ePTFE) graft, and segmental aneurysm wall resected with aneurysmorrhaphy is described. Early complications occurred in 1 patient with an ePTFE graft. The patient returned to the operating room for bleeding. In addition, the same patient had a late graft thrombosis 6 years postoperatively when the anticoagulation was discontinued for pregnancy. The remainder of the patients recovered without complication, and their repairs are still patent with a mean follow-up of 78 months (17-144 months). There were no mortalities in the series. CONCLUSIONS: Operative intervention for portomesenteric venous aneurysm can be done safely in select patients and should be considered in those with symptoms, rapid growth, mural thrombus, or aneurysms ≥4 cm in diameter. Repair with an autogenous interposition graft affords good long-term patency. Aneurysmorrhaphy may be performed if the remaining venous wall is of good quality.

Impact of mesocaval shunt on safe minimal liver remnant: porcine model.

AIM: To investigate the capacity of shunts to relieve portal hypertension and decrease the safe minimal liver remnant in pigs. METHODS: A subtotal hepatectomy with < 60 mL blood loss and without hepatic pedicle occlusion was performed. The mesenteric venous inflow was diverted through a mesocaval shunt (MCS) constructed using the prepared left renal vein with an end-to-side running suture of 5-0 proline. All 21 animals that underwent subtotal hepatectomy and/or MCS were divided into three groups. In the 15% group, the residual volume was 14%-19% of total liver volume (TLV); in the 15%+ S group, the residual volume was also 14%-19% of TLV with a mesocaval shunt (MCS); and in the 10%+ S group, the residual volume was 8%-13% of TLV with an MCS. In the three groups, the intraoperative portal vein pressure (PVP) and portal vein flow (PVF) were monitored and compared at laparotomy and 1 h post-hepatectomy. The survival rate, sinusoidal endothelial damage, tissue analysis, and serum analysis were investigated among the three groups. RESULTS: The percentage residual liver volume was 15.9%, 16.1% and 11.8% in the 15%, 15%+ S, 10%+ S groups, respectively. After hepatectomy, PVF and portal-to-arterial flow ratio in the 15%+ S group significantly decreased and hepatic artery flow (HAF) per unit volume significantly increased, compared to those in the 15% group. The PVP in the 15%+ S group and 10%+ S group increased slightly from that measured at laparotomy; however, in the 15% group, the PVP increased immediately and significantly above that observed in the other two groups. The 14-d survival rates were 28.5%, 85.6%, and 14.2% in the 15%, 15%+ S, and 10%+ S groups, respectively. In the 15%+ S group, the shunts effectively attenuated injury to the sinusoidal endothelium, and the changes in the serum and tissue analysis results were significantly reduced compared to those in the 15% and 10%+ S groups. CONCLUSION: MCS can decompress the portal vein and so attenuate liver injury from hyperperfusion, and make extreme or marginal hepatectomy safer.

Renal vein extension using an autologous renal vein in a living donor with double inferior vena cava: a case report.

BACKGROUND: When the kidney from a living donor with a double inferior vena cava (IVC) is harvested for renal transplantation, the short length of the renal vein may eventually create a technical problem for graft implantation. Herein, we have reported a rare case of renal vein extension using an autologous renal vein in a living donor with a double IVC. CASE REPORT: A 70-year-old man with end-stage renal disease owing to autosomal-dominant polycystic kidney disease underwent a living donor kidney graft from his wife who had a double IVC. Because of the enlarged kidneys, the patient underwent a bilateral native nephrectomy with concomitant renal transplantation to create space in the pelvis. At nephrectomy, the recipient's renal vein was used to extend the donor renal vein. On the back table, the vein graft was sutured to the donor renal vein, permitting a 3.0-cm extension. RESULTS: The transplantation was performed safely without any complications; the recipient's renal function and blood flow were excellent after the operation. CONCLUSION: This case illustrated that an autologous renal vein graft is a preferable option to extend of short donor renal vein for recipients who require a simultaneous native nephrectomy.

Renal vein lengthening using gonadal vein reduces surgical difficulty in living-donor kidney transplantation.

BACKGROUND: During living-donor kidney transplantation, to maximally decrease donor injury, the right kidney with lower glomerular filtration rate often is selected as the donor kidney. However, the renal vein of the right kidney is relatively short for transplantation. The gonadal vein is essentially useless and is easily accessed during the donor nephrectomy. METHODS: Seventeen live kidney donors received right kidney nephrectomy for living-donor kidney transplantation. Short renal veins were lengthened by circular anastomosis or spiral anastomosis of longitudinally cut gonadal veins. The renal function of receivers was evaluated using creatinine clearance. RESULTS: The renal veins were extended by 2.0-2.7 cm with circular anastomosis and 4.1-4.5 cm with spiral anastomosis with an average of 2.5 ± 0.7 cm. Lengthening of renal veins averaged 20.4 ± 4.2 min. All surgeries were successful, significantly reducing difficulty of vascular anastomosis during transplantation. No poor early graft function occurred. No side effects were observed in donors. CONCLUSIONS: When donor renal veins are too short for effective kidney transplantation and may affect reliability of vascular anastomosis, they can be lengthened by using gonadal veins without increasing injury to the donor. Successful extension of donor kidney renal veins expands the indication for right donor kidneys.

Potential use of left renal vein graft in pancreaticoduodenectomy combined with long segmental resection of the superior mesenteric-splenic-portal vein confluence.

CONTEXT: Various techniques for reconstruction after superior mesenteric-splenic-portal vein confluence resection during pancreaticoduodenectomy have been introduced. A certain kind of vascular grafting may be necessary especially when long segmental resection of superior mesenteric-splenic-portal vein confluence is required. CASE REPORT: We herein report the cases of two patients who underwent left renal vein grafting in a pancreaticoduodenectomy with combined resection of the long segment of the superior mesenteric-splenic-portal vein confluence for pancreatic head cancer following neoadjuvant concurrent chemoradiation therapy as well as their long-term outcomes with graft patency without deterioration of renal function. CONCLUSION: Our experience with these two cases indicates that an autologous interposition graft using the left renal vein may be considered a safe and convenient conduit in the case of long segmental resection of the superior mesenteric-splenic-portal vein confluence during a pancreaticoduodenectomy following preoperative neoadjuvant chemoradiation therapy.

Transplant renoportal vein conduit for complete mesenteric thrombosis: a case report.

Portal vein thrombosis, which is present in up to one quarter of patients with end-stage liver disease, presents a technical challenge at the time of liver transplantation. Thromboendovenectomy when feasible has been advocated in these patients. However, in patients with complete mesenteric thrombosis where this technique is typically not successful, a number of alternative techniques have been attempted including caval transposition, portal arterialization, and multivisceral transplantation often with discouraging results. We present herein a single case where transplant renal vein outflow was used to provide portal vein inflow in a patient with complete mesenteric thrombosis undergoing simultaneous liver-kidney transplant.

Changes in cytokine concentrations in graft renal vein during reperfusion in patients with and without delayed graft function.

INTRODUCTION: The impairment of organ function derived from ischemia-reperfusion injury is still an important problem in solid organ transplantation. Cell alterations induced by ischemia prime the tissue for the subsequent damage that occurs during the reperfusion phase. Despite recent advances in immunosuppressive therapy, delayed graft function (DGF) remains an important problem after kidney transplantation. Different studies have related various clinical factors to DGF, such as donor age, recipient age, cold ischemia time, initial immunosuppressive regimens. The aim of present study was to examine the changes in cytokine concentrations in graft renal vein during the reperfusion in relation to the development of delayed graft function. MATERIAL AND METHODS: The study included 17 recipients of cadaveric renal grafts (10 males, 7 females, mean age 49 +/- 7 years, cold ischemia time 25 +/- 3 h)--8 with DGF and 9 without DGF. Levels of IL-lbeta, IL-2, IL-4, IL-6, IL-8, IL-10, IFN-gamma, TNF-beta and TNF-alpha in renal graft vein plasma during 5 first min. of reperfusion were quantified by flow-cytometry. RESULTS: The increased concentrations ofIL-6, TNF-alpha and IL-1beta were observed during reperfusion. However there were no statistically significant differences between patients with and without DGF.

Purine and cytokine concentrations in the renal vein of the allograft during reperfusion.

The impairment of organ function derived from ischemia-reperfusion injury is still an important problem in solid organ transplantation. Cell alterations induced by ischemia prime the tissue for subsequent damage during the reperfusion phase. The aim of present study was to examine the association between changes in cytokine and purine metabolite concentrations in graft renal vein during reperfusion. The study included 17 recipients of cadaveric renal grafts: 10 men and seven women of overall mean age of 49 +/- 7 years and cold ischemia time 25 +/- 3 hour. The levels of interleukin (IL)-1beta, IL-2, IL-4, IL-6, IL-10, interferon (INF)-gamma, tumor necrosis factor (TNF)-beta, and TNF-alpha in renal graft vein plasma during 5 first minutes of reperfusion were quantified by flow cytometry. Increased concentrations of IL-6, TNF-alpha, and IL-1beta were observed during reperfusion. The IFN-gamma concentrations correlated negatively with xanthine (Xan) concentrations in renal vein blood during reperfusion, whereas there was a positive correlation between IL-2 and Xan concentrations. Moreover, the concentrations of IL-6 and IL-10 correlated negatively with hypoxanthine concentrations, and the concentrations of IL-4 also correlated negatively with Xan concentrations. The results of this study indicated the enhanced release of some cytokines during kidney graft reperfusion. It occurred in association with release of purine metabolites-the markers of energy status of renal tissue. Therefore, the enhanced cytokine production during reperfusion might influence ischemia-reperfusion injury and the early graft function.

An innovative option for venous reconstruction after pancreaticoduodenectomy: the left renal vein.

INTRODUCTION: Pancreatic ductal adenocarcinoma has a high mortality rate with limited treatment options. One option is pancreaticoduodenectomy, although complete resection may require venous resection. Pancreaticoduodenectomy with venous resection and reconstruction is becoming a more common practice with many choices for venous reconstruction. We describe the technique of using the left renal vein as a conduit for venous reconstruction during pancreaticoduodenectomy. METHODS: The technique for use of the left renal vein as an interposition graft for venous reconstruction during pancreaticoduodenectomy is described as well as outcomes for nine patients that have undergone the procedure. RESULTS: Nine patients, seven men, with a mean age of 57 years, have undergone the operation. There were eight interposition grafts and one patch graft. Mean operating time was 7.8 hours, and mean tumor size was 3.4 cm. Eight patients had node-positive disease, and six had involvement of the vein. Mean hospital stay was 14 days and perioperative morbidity included a superficial wound infection, delayed gastric emptying, ascites, and gastrointestinal bleeding in one patient each. Creatinine ranged from 0.8-1.1 mg/dl preoperatively and from 0.7-1.3 mg/dl at discharge. Mean follow-up was 6.8 months with normal creatinine values noted through the follow-up period. Two patients had died during follow-up from recurrent disease at 8.3 and 18.2 months after the operation. CONCLUSIONS: The left renal vein provides an additional choice for an autologous graft during pancreaticoduodenectomy with venous resection. The ease of harvesting the graft and maintenance of renal function distinguish its use.

Portal vein reconstruction using a left renal vein graft for a patient with hilar cholangiocarcinoma.

We report a patient with hilar cholangiocarcinoma who underwent combined portal vein reconstruction using a left renal vein graft. A 68-year-old man was referred to the hospital with a one-week history of dark urine and jaundice. Cholangiography through the percutaneous transhepatic biliary drainage catheter and magnetic resonance cholangiopancreatography demonstrated complete obstruction of the hepatic primary confluence extended to the left secondary confluence. The patient underwent left hepatic lobectomy combined with total caudate lobectomy and extrahepatic bile duct resection. At operation, carcinoma invasion was observed from the portal trunk to the right portal branch. So, combined portal vein resection and graft interpose using left renal vein was performed. The caliber of left renal vein was wider than the right portal branch. No remarkable renal and hepatic dysfunction occurred postoperatively. In conclusion, left renal vein seems appropriate as an autograft when reconstructing the portal vein, especially main portal trunk, in patients with advanced hepatobiliary malignancies. It may be necessary to adjust the caliber when anastomosing the left renal vein to the right or left portal branch because the diameter of the left renal vein is usually wide.

ENDO-GIA staplers for side-to-side anastomosis of veins.

OBJECTIVE: To study the application of ENDO-GIA staplers for the side-to-side anastomosis of veins. MATERIALS AND METHODS: An animal study was conducted. Five dogs received side-to-side anastomosis of allograft IVC by ENDO-GIA staplers (Group 1). In addition, five received the same operation with right renal vein reimplantation to allograft IVC (Group 2). Five dogs, receiving the same operation as in Group 1 using polypropylene sutures (control group, Group 3). An autopsy was performed if the dogs survived more than 8 weeks. RESULTS: The IVC anastomosis remained patent in four subjects (80%) for Group 1, in five subjects (100%) for Group 2 and in four subjects (80%) for Group 3. CONCLUSIONS: From the results of our experiment, ENDO-GIA staplers can be considered for use in the side-to-side anastomosis of large veins such as piggyback cavacaval side-to-side anastomosis in cadaveric orthotopic liver transplantation (OLT) or side-to-side splenorenal shunt in portal hypertension.