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Hepatic artery reconstruction is one of the key procedures in liver transplantation. Accidental dissection of the hepatic artery to be reconstructed caused by donor and recipient factors or surgical factors will disrupt the surgical plan, increase the difficulty of arterial reconstruction, significantly prolong the operation time, increase the risk of postoperative arterial stenosis and thrombosis and probably lead to acute allograft failure, which requires emergency surgical interventions or even secondary liver transplantation. Understanding of how to avoid dissection of the artery to be anastomosed during liver transplantation and corresponding treatment will contribute to preventing the incidence of artery-related complications during liver transplantation and improving clinical prognosis of liver transplant recipients. In this article, the causes, prevention and treatment of hepatic artery dissection and hepatic artery reconstruction in donors and recipients during liver transplantation were illustrated.
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Objective To summarize clinical experience of transabdominal pericardial anastomosis of suprahepatic vena cava of the donor and right atrium of the recipient in liver transplantation for Budd-Chiari syndrome (BCS) complicated with liver cancer. Methods Clinical data of a BCS patient complicated with liver cancer undergoing transabdominal pericardial anastomosis of suprahepatic vena cava and right atrium in liver transplantation were retrospectively analyzed. Results The hepatic vein and suprahepatic vena cava were partially occluded in the patient. Liver transplantation was completed by transabdominal pericardial anastomosis of suprahepatic vena cava and right atrium with beating-heart. In addition, due to pathological changes of the recipient's hepatic artery, splenic artery of the recipient was cut off, distal ligation was performed, and the proximal end was reversed and anastomosed with the common hepatic artery of the donor liver, and the reconstruction of hepatic artery was completed. The surgery was successfully performed. At approximately postoperative 1 week, the function of the liver allograft was gradually restored to normal, and no major complications occurred. The patient was discharged at postoperative 25 d. No signs of BCS recurrence was reported after 8-month follow-up. Conclusions It is safe and feasible to treat BCS by liver transplantation with transabdominal pericardial anastomosis of suprahepatic vena cava and right atrium. BCS patients complicated with liver cancer obtain favorable prognosis.
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Objective To evaluate the effect of different techniques of hepatic artery reconstruction on postoperative hepatic artery complications and clinical prognosis in liver transplantation. Methods Clinical data of 140 liver transplant recipients were retrospectively analyzed. All recipients were divided into the conventional hepatic artery reconstruction group (n=123) and special hepatic artery reconstruction group (n=17) according to hepatic artery reconstruction methods. Intraoperative and postoperative clinical indexes, the incidence of postoperative hepatic artery complications and survival rate were compared between two groups. Results The alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels at postoperative 1 d, total bilirubin (TB) at postoperative 7 d and prothrombin time international normalized ratio (PT-INR) at postoperative 30 d in special hepatic artery reconstruction group were higher than those in conventional hepatic artery reconstruction group, and the differences were statistically significant (all P < 0.05). There were no significant differences in the operation time, anhepatic phase, intraoperative blood loss, intraoperative transfusion volume of red blood cells, cold or warm ischemia time, the length of intensive care unit (ICU) stay, the length of hospital stay and postoperative blood flow of liver allograft between two groups (all P > 0.05). In the conventional hepatic artery reconstruction group, 5 recipients developed hepatic artery complications, whereas no hepatic artery complications occurred in the special hepatic artery reconstruction group, with no significant difference between two groups (P > 0.05). In the special hepatic artery reconstruction group, the 1-, 3- and 5-year cumulative survival rates were equally 82.4%, compared with 85.0%, 78.9% and 75.6% in the conventional hepatic artery reconstruction group, respectively. There was no significant difference between two groups (all P > 0.05). Conclusions When hepatic artery variations and (or) lesions are detected in donors and recipients, use of special hepatic artery reconstruction may effectively restore the hepatic arterial blood flow of liver allograft after liver transplantation, and will not affect the incidence of hepatic artery complications and survival rate of the recipients following liver transplantation.
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Objective To compare the difference of clinical efficacy between surgical magnifying glass and surgical microscope assisted hepatic artery reconstruction in living donor liver transplantation (LDLT). Methods Clinical data of 272 donors and recipients undergoing LDLT were retrospectively analyzed. According to different patterns of hepatic artery reconstruction, all recipients were divided into the magnifying glass group (n=189) and microscope group (n=83). The operation time, intraoperative blood loss, hepatic artery reconstruction site, diameter of anastomosis, incidence of postoperative complications and survival rate of recipients were statistically compared between two groups. Results Compared with the microscope group, the operation time, hepatic artery reconstruction time and intraoperative blood loss were significantly less in the magnifying glass group (all P < 0.001). The most common site of hepatic artery reconstruction was the right hepatic artery in two groups, and the diameter of anastomosis was (2.1±0.9) mm in the magnifying glass group and (2.1±0.8) mm in the microscope group, with no statistical significance between two groups (P > 0.05). The 1-, 2- and 3-year survival rates of recipients in the magnifying glass group were 88%, 86% and 85%, which did not significantly differ from 89%, 87% and 86% in the microscope group (all P > 0.05). The incidence of postoperative complications did not significantly differ between two groups (all P > 0.05). Conclusions The efficacy and safety of hepatic artery reconstruction in LDLT under surgical magnifying glass are equivalent to those under surgical microscope, with less operation workload and intraoperative blood loss. For experienced transplantation surgeons, it is recommended to perform hepatic artery reconstruction assisted by surgical magnifying glass.
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Objective To study the combined use of ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) with hepatic artery reconstruction in the treatment of hilar cholangiocarcinoma with hepatic arterial involvement.Methods The clinical data of 7 patients with hilar cholangiocarcinoma who underwent ALPPS combined with hepatic arterial resection and reconstruction were analyzed retrospectively.The technical points and the perioperative management were analyzed.Methods At the first stage,the relationship between the tumor and the vessels were explored,the portal vein of the part of the liver to be resected was ligated and the liver was transected with a CUSA (Cavitron Ultrasound Surgical Aspirator).Then the bile duct was cut and a hepaticojejunostomy was completed.Finally,under ultrasound guidance,a bile duct drainage tube was inserted transhepatically into the part of the liver which was to be resected.Two to three weeks later,and after enough hypertrophy of the liver remnant size was confirmed,tumor resection was completed with reconstruction of the hepatic artery.Results Seven patients underwent the second stage operation,with no perioperative death.Six patients developed pulmonary infection and were treated successfully with conservative treatment.Two patients developed postoperative bile leak with secondary abdominal infection.One patient developed postoperative hepatic artery thrombosis secondary to biliary tract infection.Conclusion ALPPS combined with hepatic artery reconstruction was safe and feasible in the treatment of hilar cholangiocarcinoma with hepatic arterial involvement.
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Securing the source of hepatic artery inflow is essential for living donor liver transplantation. However, sometimes, the hepatic arteries of the recipients are in poor condition for a good anastomosis in living donor liver transplantation; problems include severe arteriosclerosis, intimal dissection, and significant intimal injuries caused by previous transarterial procedures. In these conditions, the right gastroepiploic artery has generally been the preferred artery because of its anatomical location, size and length. Here, a case of successful hepatic artery reconstruction is reported using the right gastroepiploic artery in living donor liver transplantation. The recipient's hepatic arterial intima was severely injured by multiple transarterial chemoembolization and unsuitable for reconstruction. Instead, the right gastroepiploic artery was anastomosed to the hepatic artery of the graft. Arterial blood flow was satisfactory on Doppler ultrasonography during the operation, and complications related to the hepatic artery were not detected during the follow-up period. Therefore, the right gastroepiploic artery may be considered as a suitable alternative for hepatic artery reconstruction in living donor liver transplantation.
Subject(s)
Humans , Arteries , Arteriosclerosis , Follow-Up Studies , Gastroepiploic Artery , Hepatic Artery , Liver , Liver Transplantation , Living Donors , Transplants , Tunica Intima , Ultrasonography, DopplerABSTRACT
PURPOSE: During liver transplantation (LT), complications of the hepatic artery have been decreased because of microsurgery in reconstruction of hepatic artery has been widely adopted. However, in an early step of the LT program, hepatic artery reconstruction generally tends to be done with the help of a micro-surgeon from the the plastic surgery in most of Korean medical centers. In our center, we also have done reconstruction of the hepatic artery using a microscope and the skills of a plastic surgeon. We did this between Feb, 2005 and Jun, 2008 for liver transplantations. The increased the need for micro-surgeons in liver surgery as increased the cases of liver transplantation steadily. After training general surgeons of the surgical department who had no experience with microsurgery, we invested in the micro-surgery of hepatic artery reconstruction. Here we report the result of that investment. METHODS: Liver transplant patients (n=176) were enrolled between Feb, 2005 and Jul, 2009. Between Jul, 2008 and Jul, 2009, 28 cases of reconstruction of the hepatic artery were done by a general surgeon who had micro-surgery training. Before training in hepatic artery reconstruction, the general surgeon spent 3 months being introduced to micro-surgery in the micro animal laboratory. Because the training was repeated, the surgeon became skilled in doing artery anastomosis using rat's abdominal aorta. At the same time, we trained a plastic surgeon to do hepatic artery reconstruction during liver transplantation as the first assistant. From Jul, 2008 to the present time, the general surgeon was exclusively in charge of hepatic artery reconstruction during liver transplantation. Hepatic artery reconstruction was done using a microscope. Stitching was done using 8-0 or 9-0 nylon, and an interrupted end-to-end anastomosis was done. After hepatic artery reconstruction, artery flow was confirmed by ultrasonic doppler. For group A patients, left lobe grafts were used in 33, right lobe grafts in 73, dual grafts in 6, and whole liver grafts in 36. RESULTS: For group B patients, left lobe grafts were used in 1 and right lobe grafts in 21, while whole liver grafts were used in 6. In Group A, hepatic artery complications occurred in 5 cases (3.3%), and in Group B such complications did not occur (0%). There was no statistical difference (p=0.312). CONCLUSION: For hepatic artery reconstruction, during micro-surgery under a surgical microscope, it is thought that it is best to invest in a general surgeon who has been trained in micro-surgery. We suggest that a general surgeon is suitable for hepatic artery reconstruction after only a short time of micro surgery training.
Subject(s)
Animals , Humans , Aorta, Abdominal , Arteries , Fees and Charges , Hepatic Artery , Investments , Liver , Liver Transplantation , Microsurgery , Nylons , Surgery, Plastic , Transplants , UltrasonicsABSTRACT
Objective To observe the effects of hepatic artery reconstruction in rat with orthotopic liver transplantation(OLT)on ultrastructure changes of intrahepatic biliary epithelial cells after ischemia reperfusion iniury and postoperative biliary complications. Methods Male SD rats were divided into sham operation group (SO),OLT with hepatic artery reconstruction group(HA)and OLT without hepatic artery reconstruction group (NA).The liver tissue samples were collected at 0.5,3,6,12,24,36,48 hours after ischemia reperfusion in both HA grouD and NA group.The uhrastructure of intrahepatic biliary epithelial cells was observed by transmission electron microscope,and the morphometric analysis by the computer image analysis system.The postoperative biliary complications were also observed.Results In HA group and NA group,the injury of intrahepatic biliary epithelial cells aggravated gradually along with the reperfusion.The uhrastructure changes,such as enlarged mitochondria,blurred or disappeared cristae and decreased number of microvilli,were most significant at 24 hours and then recovered gradually.The mitochondrial average area and average perimeter were increased and the mitochondrial numerical densitv was decreased gradually along with the reperfusion.At 24,36,48 hours,the mitochondrial average area and average perimeter in NA group were significantly greater than those in HA group(t=-3.566,-7.780,-4.730,-4.610,-2.599,-5.730,P＜0.05).The average numerial density of mitochondia in NA group was significantly less than that in HA group at 36,48 hours(t=-4.619,4.000,P＜0.05).The incidence rate of biliary complications in HA group is significantly lower than that in NA group(x2=4.286,P＜0.05).Conclusions Hepatic artery reconstruction in rat with OLT has an protective effect on the uhrastructure of intrahepatic biliary epithelial cells after ischemia reperfusion.It is beneficial to the recovery of intrahepatic bile duct epithelial cells and can reduce the incidence rate of biliary complications.
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Objective To summarize the experience in hepatic artery reconstruction in adult-to-adult living donor liver transplantation(ALDLT).Methods Fifty patients underwent ALDLT in our hospital from January 2002 to July 2006.All the hepatic a~ery reconstructions were done under surgical microscope.ResultsTwo patients(4%)presented with hepatic artery thrombosis.All the patients were followed up for 2 to 52 months (median,9 months),and no hepatic artery stenosis nor hepatic artery pseudoaneurysm occurred.The 1-year survival rate was 92%(46/50).Conclusions Systematic evaluation of hepatic artery reconstruction and use of microsurgical technique are key to the reduction of complications of hepatic artery reconstruction in ALDLT.