Non-standard hepatic venous reconstruction in the setting of absent inferior vena cava in partial graft pediatric liver transplantation-A matched retrospective cohort study.

Recipient cava may be unavailable for outflow reconstruction in some children undergoing liver transplantation (PLT) due to caval agenesis, tumor, or fibrotic caval occlusion. Non-standard hepatic venous reconstruction (NHVR) with a direct veno-caval anastomosis or neo-cava reconstruction is necessary in such cases. Retrospective review of all PLT needing NHVR performed in our unit from January 2010 to September 2019 was performed. Outcomes of this group were compared to a 2:1 matched control group who underwent transplantation with standard piggyback technique. Fifteen children (4.9%) of 304 PLT recipients underwent NHVR. Caval agenesis in biliary atresia (n = 5, 33%) and hepatoblastoma infiltrating the cava (n = 4, 27%) were the commonest indications. Ten children had neo-cava reconstruction, while 5 had direct anastomosis to the supra-hepatic caval cuff or right atrium. One child had developed neo-cava thrombosis without graft venous outflow obstruction in the post-operative period. There was no significant difference in major morbidity, need for re-operation (20% vs 16.7%; P = 1.00), hospital stay (24 days, vs 21 days; P = .32), graft & patient survival among the study and control groups. Absent or inadequate recipient cava during PLT with a partial liver graft can be safely managed with technical modifications. Results equivalent to standard piggyback implantation can be achieved.

Surgical Procedures of Portal Vein Reconstruction for Recipients With Portal Vein Thrombosis in Adult-to-Adult Living Donor Liver Transplantation.

BACKGROUND: Portal vein (PV) reconstruction is an important surgical skill for living donor liver transplantation (LDLT), especially for patients with portal vein thrombosis (PVT). However, this technique remains a critical problem in LDLT because of technical demands and requirements for appropriate venous graft harvesting. This study aimed to evaluate the surgical procedure used for PV reconstruction and outcomes in LDLT recipients with PVT. METHODS: Between March 2002 and December 2018, 128 adult LDLTs were performed. Fourteen recipients (10.8%) had PVT at the time of LDLT, classified as grade I in 2, grade II in 5, grade III in 6, and grade IV in 1, according to the Yerdel classification. We retrospectively analyzed the surgical procedure and postoperative complications associated with PV reconstruction of recipients with PVT. RESULTS: Surgical treatments for 14 recipients with PVT were as follows: thrombectomies in 2 recipients, replacement of interpositional venous grafts using the internal jugular vein (IJV) in 3 recipients and the external iliac vein (EIV) in 6 recipients, mesoportal jump grafts using the IJV in 1 recipient and the IJV + EIV in 1 recipient, and renoportal anastomosis using the EIV in 1 recipient. Among interpositional venous grafts, 5 venous grafts (IJV: 2, EIV: 3) passed the dorsal side of the pancreas without using the jump graft. Postoperative complications associated with PV anastomosis occurred in 1 of 14 (7.1%) recipients, who developed anastomosis bleeding caused by coagulation disorders at 27 days after LDLT, without any strictures of PV anastomoses. The overall survival rate at 5 years posttransplant was not statistically different between recipients with and without PVT (50.0% vs 65.0%, P = .163). CONCLUSION: Our techniques of PV reconstruction, using the appropriate venous grafts and route, are feasible, resulting in a prognosis comparable to that of recipients without PVT.

Use of a donor iliac vein graft for reconstruction of the inferior vena cava in liver transplantation for hepatoblastoma with caval extension.

Complete microscopic tumor resection is critical for successful treatment of hepatoblastoma, and this may include when liver transplantation is required. For tumors involving the IVC or PV, complete resection should include the involved IVC or PV to ensure full tumor clearance. When this is required, the venous reconstruction at transplant or post-excision can be challenging. We present the management of an 18-month-old girl with PRETEXT Stage IV (P, V, F) hepatoblastoma and IVC involvement, where native caval resection and reconstruction was required. The preoperative staging following neoadjuvant chemotherapy was POSTTEXT Stage IV (P, V, F). An orthotopic liver transplantation was performed using a left lateral segment graft from a deceased adult donor. With native hepatectomy, retrohepatic IVC resection from just above the hepatic venous confluence to just above the entry of the right adrenal vein was performed. For caval reconstruction, a venous graft from a deceased donor was used. The graft included the lower IVC with the right common iliac vein and a short stump of the left common iliac vein. The common iliac was a perfect size match for the IVC, and the three natural ostia matched the upper cava, lower cava, and the outflow from the donor left hepatic vein. The patient had an uneventful postoperative course and remains well and disease-free 2 years after transplant with continued patency of the reconstructed cava. When indicated, a donor iliac vein graft with its natural ostia should be considered in caval reconstruction for pediatric liver transplantation.

Rex Shunt as a Treatment of Type II Abernethy Malformation with Severe Dysplasia of Portal Vein.

BACKGROUND: Ligation of abnormal portosystemic shunt has been used to treat type II Abernethy malformation, but it may not be suitable for all patients. In this study, Rex shunt was carried out to manage type II Abernethy malformation with portal venous dysplasia. The outcomes are evaluated retrospectively. METHODS: Between June 2014 and January 2015, 2 boys (age: 4.8 and 12.8 years, respectively) with type II Abernethy malformation underwent Rex shunt with ligation of inferior mesenteric vein (IMV). The portal venous pressures were measured intraoperatively to decide the extent of inferior mesenteric venous ligation. An ileal vein (6 mm in diameter) and a venae sigmoideae (7 mm in diameter) were interposed between the left portal vein and superior mesenteric vein, respectively. To minimize postoperative portal hypertension, the IMV was partially ligated. Five months later, the IMV was completely ligated in a second operation because of persistent bloody stool and anemia (hemoglobin < 100 g/L). RESULTS: The duration of the operations was 180 and 240 min. The extrahepatic portal pressure increased after bypass, but the portal pressure was less than 24 cm H2O in both patients. The fecal blood loss and frequency of hemafecia decreased after surgery. The bypass vein was patent, and the portal blood flow was shown increased on postoperative ultrasound and computed tomography. There was no hypersplenism and esophageal gastric varices. CONCLUSIONS: The surgical management of Abernethy type II malformation should be individualized. Rex shunt with ligation of portosystemic shunt is feasible and effective in patients with severe dysplasia of portal vein.

Treatment of Femoral Vein Obstruction Concomitant with Iliofemoral Stenting in Patients with Severe Post-thrombotic Syndrome.

BACKGROUND: The aim was to assess the clinical and anatomical outcomes of iliofemoral stenting, with concomitant femoral stenting or balloon angioplasty alone, in patients with severe post-thrombotic syndrome (PTS) and compromised inflow. METHODS: A database of patients with severe PTS who successfully underwent endovascular iliofemoral stenting was reviewed retrospectively. Patients with impaired inflow with chronic post-thrombotic obstructive lesions in the femoral vein (FV), but patent profunda vein, were selected and divided into two groups: the FV stenting (FV-S) group and the FV angioplasty (FV-A) group. Patients in the FV-S group were treated with concomitant iliofemoral and FV stenting, and patients in the FV-A group were treated with iliofemoral stenting and balloon angioplasty alone of the obstructed femoral vein. The clinical and stent outcomes were recorded and compared in the two groups. RESULTS: There were 45 patients in the FV-S group and 69 patients in the FV-A group. The groups were well matched for age, gender, and diseased limbs. The pre-procedural symptoms, CEAP classifications, VCSS scores, Villalta scores, and prevalence of active ulcers were also similar between the two groups. Immediate failure (<30 days post-procedure) in the femoral segment occurred more frequently in the FV-A group (70% in FV-A group vs. 24% in FV-S group, p < .001); however, all treated femoral vein segments had occluded at 12 months. There was no significant difference between the FV-S and FV-A groups in cumulative primary and secondary patency rates of the iliofemoral stent at 3 years (55% vs. 52%, p = .71, and 77% vs. 85%, p = .32, respectively). Complete pain relief, swelling relief, VCSS score, Villalta score, and freedom from ulcers at a median of 22 months (1-48 months) following the procedure were similar in the two groups. CONCLUSIONS: Stent placement to treat post-thrombotic iliofemoral obstruction with concomitant obstructed femoral vein but patent profunda vein shows cumulative patency rates and clinical outcomes similar to previous reports. Adjunctive femoral stenting or angioplasty of the obstructed femoral vein does not appear to improve clinical or stent outcomes in patients with severe PTS.

Anatomy of the Internal Iliac Vein: Implications for Uterine Transplant.

STUDY OBJECTIVE: Uterine transplantation has proven feasible since the first live birth reported in 2014. To enable attachment of the uterus in the recipient, long vascular pedicles of the uterine and internal iliac vessels were obtained during donor hysterectomy, which required a prolonged laparotomy to the living donors. To assist further attempts at uterine transplantation, our video serves to review literature reports of internal iliac vein anatomy and demonstrate a laparoscopic dissection of cadaver pelvic vascular anatomy. DESIGN: Observational (Canadian Task Force Classification III). SETTING: Academic anatomic laboratory. Institutional Review Board ruled that approval was not required for this study. INTERVENTION: Literature review and laparoscopic dissection of cadaveric pelvic vasculature, focusing on the internal iliac vein. MEASUREMENTS AND MAIN RESULTS: Although the internal iliac artery tends to have minimal anatomic variation, its counterpart, the internal iliac vein, shows much variation in published studies [1,2]. Relative to the internal iliac artery, the vein can lie medially or laterally. Normal anatomy is defined as some by meeting 2 criteria: bilateral common iliac vein formed by ipsilateral external and internal iliac vein at a low position and bilateral common iliac vein joining to form a right-sided inferior vena cava [2]. Reports show 79.1% of people have normal internal iliac vein anatomy by these criteria [2]. The cadaver dissection revealed internal iliac vein anatomy meeting criteria for normal anatomy. CONCLUSION: Understanding the complexity and variations of internal iliac vein anatomy can assist future trials of uterine transplantation.

Inferior Vena Cava Replacement in Living-Donor Liver Transplant for Hepatocellular Carcinoma: First Case Report in Saudi Arabia.

Living-donor liver transplant for hepatocellular carcinoma located on hepatocaval confluence or in contact with the inferior vena cava is technically challenging, and candidates for this kind of procedure should be carefully selected. It is difficult to rule out major vascular invasion except after hepatectomy and histologic examination; in addition, the possible dissemination of cancer cells during recipient hepatectomy is a considerable risk. Herein, we report the first case in Saudi Arabia of right lobe living-donor liver transplant combined with inferior vena cava reconstruction using cryopreserved iliac vein graft after en bloc resection of the liver with part of the diaphragm, anterior wall of retrohepatic inferior vena cava, and a 5-cm hepatocellular carcinoma in segment 7. Our patient achieved so far 3-year disease-free survival. Tumor recurrence and risk of thrombosis related to inferior vena cava reconstruction are the main concerns; therefore, long-term follow-up of those patients is mandatory.

Portal vein reconstruction using primary anastomosis or venous interposition allograft in pancreatic surgery.

OBJECTIVE: Superior mesenteric vein/portal vein (SMV/PV) resection and reconstruction during pancreatic surgery are increasingly common. Several reconstruction techniques exist. The aim of this study was to evaluate characteristics of patients and clinical outcomes for SMV/PV reconstruction using interposed cold-stored cadaveric venous allograft (AG+) or primary end-to-end anastomosis (AG-) after segmental vein resections during pancreatic surgery. METHODS: All patients undergoing pancreatic surgery with SMV/PV resection and reconstruction from 2006 to 2015 were identified. Clinical and histopathologic outcomes as well as preoperative and postoperative radiologic findings were assessed. RESULTS: A total of 171 patients were identified. The study included 42 and 71 patients reconstructed with AG+ and AG-, respectively. Patients in the AG+ group had longer mean operative time (506 minutes [standard deviation, 83 minutes] for AG+ vs 420 minutes [standard deviation, 91 minutes] for AG-; P < .01) and more intraoperative bleeding (median, 1000 mL [interquartile range (IQR), 650-2200 mL] for AG+ vs 600 mL [IQR, 300-1000 mL] for AG-; P < .01). Neoadjuvant therapy was administered more frequently for patients in the AG+ group (23.8% vs 8.5%; P = .02). Patients with AG+ had a longer length of tumor-vein involvement (median, 2.4 cm [IQR, 1.6-3.0 cm] for AG+ vs 1.8 cm [IQR, 1.2-2.4 cm] for AG-; P = .01), and a higher number of patients had a tumor-vein interface >180 degrees (35.7% for AG+ vs 21.1% for AG-; P = .02). There was no difference in number of patients with major complications (42.9% for AG+ vs 36.6% for AG-; P = .51) or early failure at the reconstruction site (9.5% for AG+ vs 8.5% for AG-; P = 1). A subgroup analysis of 10 patients in the AG+ group revealed the presence of donor-specific antibodies in all patients. CONCLUSIONS: The short-term outcome of SMV/PV reconstruction with interposed cold-stored cadaveric venous allografts is comparable to that of reconstruction with primary end-to-end anastomosis. Graft rejection could be a contributing factor to severe stenosis in patients reconstructed with allograft.

Liver Transplantation in Patients With Complete Portal Vein Thrombosis: Renoportal or Varicoportal Anastomosis Using Cryopreserved Vein Grafts.

BACKGROUND: Despite technical developments in transplantation surgery, complete portal vein thrombosis still remains a challenge for restoration of adequate portal vein inflow. Renoportal or varicoportal anastomosis provides an effective alternative solution for patients with complete portal vein thrombosis. This study describes our experience with renoportal and varicoportal anastomosis during liver transplantation. PATIENTS AND METHODS: Between January 2014 and May 2016, 5 patients with complete portal vein thrombosis underwent extra-anatomic portal anastomosis. In 3 cases, varicoportal anastomosis was performed and for the others, end-to-end renoportal anastomosis. We used iliac cryopreserved vein grafts to restore portal anastomosis in 3 cases. Epidemiology, risk factors, surgical techniques, complications, and outcomes of these procedures were evaluated over short- and long-term follow-ups. RESULTS: The follow-up time is 3 years for our first renoportal case, which was performed in a cadaveric liver transplantation; it was also first nationwide case. The other renoportal anastomosis was practiced in a living donor liver transplantation and the follow-up time is 8 months. The patient and graft survival rates were 100% at the last follow-up. The follow-up times are 10.9 and 4 months for the patients with varicoportal anastomosis. One of these patients died due to recurrence of hepatocellular carcinoma. The other two patients are alive with good graft functions. CONCLUSION: Our experience suggests that reno-varicoportal anastomosis is a useful technique for patients with complete portal vein thrombosis and cryopreserved grafts may be safely used.

Domino Reconstruction of the Portal Vein Using the External Iliac Vein and an ePTFE Graft in Pancreatic Surgery.

BACKGROUND: In the portal vein resection of long distance, an interposition by autologous vein is mandatory. External iliac vein (EIV) has been used, but harvesting the EIV is associated with severe venous congestion of the affected lower extremity. We have reconstructed the EIV using a ringed expanded polytetrafluoroethylene (ePTFE) graft. METHODS: Thirteen patients underwent this surgery. The right EIV was used for reconstructing the portal vein, and the retrieved portion of EIV was interposed by the ePTFE graft. We evaluated size and length of the graft, graft patency, girth of thigh, time for reconstruction of EIV, and graft infection. RESULTS: ePTFE grafts of 8 or 10 mm in diameter were used. The length of ePTFE graft used was 4.4 ± 0.5 cm. Graft patency was kept in 76.9% patients. Graft obstruction was encountered in three patients, and the girth of right thigh increased by about 10 cm. Time for reconstruction of EIV was 29.5 ± 6.8 min. Graft infection did not occur in any patients. CONCLUSIONS: Reconstruction of the EIV using a ringed ePTFE graft seems to be a feasible option for preventing the swelling of the affected lower extremity after procurement of EIV for repairing the portal vein.

Cold-stored cadaveric venous allograft for superior mesenteric/portal vein reconstruction during pancreatic surgery.

BACKGROUND: SMV/PV resection has become common practice in pancreatic surgery. The aim of this study was to evaluate the technical feasibility and surgical outcome of using cold-stored cadaveric venous allografts (AG) for superior mesenteric vein (SMV) and portal vein (PV) reconstruction during pancreatectomy. METHODS: Patients who underwent pancreatic resection with concomitant vascular resection and reconstruction with AG between January 2006 and December 2014 were identified from our institutional prospective database. Medical records and pre- and postoperative CT-images were reviewed. RESULTS: Forty-five patients underwent SMV/PV reconstruction with AG interposition (n = 37) or AG patch (n = 8). The median operative time and blood loss were 488 min (IQR: 450-551) and 900 ml (IQR: 600-2000), respectively. Major morbidity (Clavien ≥ III) occurred in 16 patients. Four patients were reoperated (thrombosis n = 2, graft kinking/low flow n = 2) and in-hospital mortality occurred in two patients. On last available CT scan, 3 patients had thrombosis, all of whom also had local recurrence. Estimated cumulative patency rate (reduction in SMV/PV luminal diameter <70% and no thrombosis) at 12 months was 52%. CONCLUSION: Cold-stored cadaveric venous AG for SMV/PV reconstruction during pancreatic surgery is safe and associated with acceptable long-term patency.

Resection of portal and/or superior mesenteric vein and reconstruction by using allogeneic vein for pT3 pancreatic cancer.

BACKGROUND AND AIM: There is still controversy on the outcomes of portal vein (PV) and/or superior mesenteric vein (SMV) resection in pancreatic cancer, and there are few reports about pancreaticoduodenectomy (PD) with PV/SMV resection and reconstruction by using allogeneic vein. This study is to explore the outcomes of PD with PV/SMV resection and reconstruction by using allogeneic vein for pT3 pancreatic cancer with venous invasion. METHODS: Clinicopathological data of patients underwent PD with en bloc resection of PV/SMV and reconstruction by using internal iliac from August 20, 2013 to July 25, 2015 were collected and the data of patients with pT3 stage pancreatic head cancer with PV/SMV invasion were analyzed. The short- and long-term outcomes were presented. RESULTS: Thirty patients met the criteria of this study. PV resection and reconstruction were performed for 12 patients, SMV for 9 patients, and PV + SMV for 9 patients, respectively. The median operation time was 460 min, and the median intraoperative blood loss was 450 mL. R0 resection rate was 93.3%, total incidence of complications was 23.3%, and incidence of pancreatic fistula was 10%. The 1-year and 2-year overall survival rates were 68.6% and 39.2%, 1-year and 2-year disease free survival rates were 44.8% and 17.1%. CONCLUSIONS: PD with en bloc resection of PV/SMV and reconstruction by using allogeneic vein was safe and feasible for patients with pT3 stage pancreatic head cancer with PV/SMV invasion. A large-scale research with longer follow-up time is required to draw a significant conclusion.

Segmental portal/superior mesenteric vein resection and reconstruction with the iliac vein after pancreatoduodenectomy.

Objective The results of segmental venous resection (VR) combined with pancreatoduodenectomy (PD) are controversial but may be promising. Few studies have described reconstruction of the portal/superior mesenteric vein (PV/SMV) with the iliac vein harvested from donation after cardiac death (DCD). Methods From January 2014 to April 2016, PD combined with segmental excision of the PV/SMV (VR group) was performed in 21 patients with adenocarcinoma of the head of the pancreas (ADHP). The authors established a new technique of venous reconstruction using the iliac vein from DCD and analysed patients' long-term survival. Results The tumour dimensions and tumour staging were greater and the operation time was longer in the VR than PD group; however, no differences in the resection degree, blood loss, complications, reoperation rate, or mortality rate were found. The median survival was similar between the VR and PD groups. The long-term patency of the donor iliac vein was 90%. The degree of resection was a strong predictor of long-term survival. Conclusion Segmental PV/SMV resection combined with PD is applicable to selective patients with venous invasion by ADHP if R0 resection has probably been achieved. An iliac vein obtained by DCD provides an effective graft for venous reconstruction.

Technical options for outflow reconstruction in domino liver transplantation: A single European center experience.

Venous outflow is critical to the success of liver transplantation (LT). In domino liver transplantation (DLT), the venous cuffs should be shared between the donor and the recipient, and the length can be compromised. The aim of this study was to describe and compare the technical options for outflow reconstruction used at our institution. This was a retrospective analysis of 39 consecutive DLT recipients between January 1997 and May 2013. Twenty-seven men and 12 women (mean age, 61.8 ± 4.3 years) underwent LT and consented to receive a liver from a donor with familial amyloid polyneuropathy (FAP). The main indications were hepatocellular carcinoma and hepatitis C virus cirrhosis. All recipients underwent transplantation by a piggyback technique. Liver procurement in the FAP donors was performed with the classic technique in 22 patients and with the piggyback technique in the last 17. In these latter cases, for vascular outflow reconstruction, a cadaveric venous graft was interposed between the hepatic vein (HV) stump of the FAP liver and the recipient HV in 11 cases (28%). Since 2011, we have employed arterial grafts to be interposed between the vessels stumps: a tailored arterial graft in 5 patients and an aortic graft in 1 case. There was no postoperative mortality. Arterial and portal complications presented in 2 (5.1) and 4 patients (10.3), respectively. Postoperative outflow complications (post-LT subacute Budd-Chiari syndrome) occurred in 4 patients, and all of them had received a venous interposed graft for reconstruction. The incidence of outflow complications tended to be higher among patients with venous grafts than those with arterial graft interposition. Overall patient survival at 1, 3, 5, and 10 years was 97%, 79%, respectively. Arterial grafts constitute a feasible and safe option for vascular outflow reconstruction in DLT because they are associated with a relatively low incidence of complications. The recently proposed Bellvitge arterial graft technique should be added to the current range of available surgical modalities.

En bloc resection of the hepatoduodenal ligament for advanced biliary malignancy.

BACKGROUND: En bloc resection of the hepatoduodenal ligament (HDL) for advanced biliary malignancy by hepato-ligamento-pancreatoduodenectomy (HLPD) or hepatoligamentectomy (HL) remains challenging, and only short-term outcomes have been reported. We showed our surgical technique of HLPD and HL, and retrospectively investigated surgical outcomes of the patients. METHODS: Between 2003 and 2014, we performed four HLPD and three HL including major hepatectomy with concomitant caudate lobectomy. Portal vein reconstruction (PVR) was performed with a right external iliac vein graft, and hepatic artery reconstruction (HAR) was accomplished with the heterogeneous artery using the continuous suturing method. RESULTS: Mean operation time and blood loss were 575 ± 111 min and 1539 ± 950 mL, respectively, and patency of the reconstructed vessels was confirmed postoperatively in all cases. Histologically, negative surgical margins (R0) were achieved in 57% of patients, while the resected vascular invasion was confirmed in all patients. Overall morbidity was high at 57%, but we have achieved no postoperative mortality. Overall median survival time of the patients was 36 months, and a patient of HL survived over 5 years. CONCLUSIONS: En bloc resection of the HDL based on steady vascular reconstruction can improve the surgical outcome of biliary cancer in selected patients.

Renal vein extension during living-donor kidney transplantation in the era of hand-assisted laparoscopic living-donor nephrectomy.

BACKGROUND: To evaluate retrospectively the clinical outcomes of living-donor kidney transplantations (LDKTs) using renal vein extension (RVE) for donor kidneys with short renal veins. METHODS: Between January 2007 and December 2010, a total of 576 LDKTs were performed with grafts generated by hand-assisted laparoscopic living-donor nephrectomy: 31 (5.4%) transplants with RVE and 545 (94.6%) without an additional vascular procedure for renal vein lengthening. Outcomes were compared in patients who did and did not undergo the RVE procedure during transplantation. RESULTS: The 31 transplantation patients that underwent RVE involved procured kidneys with short renal veins: 29 were right-sided kidneys (93.5%) and 2 were left-sided kidneys (6.5%) (P=0.00). The RVE grafts were obtained from allogenic gonadal veins from female donors (n=16, 51.6%) and iliac veins from deceased donors (n=15, 48.4%). There were no postoperative complications related to the RVE procedure. During a follow-up period of 45.6±15.9 months, there were one (3.2%) graft failure among the 31 patients with RVE and four (0.7%) among the 545 patients without RVE. Delayed graft function was noted in one (3.2%) of the RVE patients and 22 (4.0%) of the patients without RVE. There was no statistically significant difference in graft failure (P=0.24) or delayed graft function (P=1.00) between the two groups. CONCLUSION: During LDKT, donor kidneys with exceptionally short renal veins, which may result in unavoidable tension during renal vein anastomosis, may be modified by RVE, thus facilitating a secure anastomosis and reducing postoperative complications.