Temporary Portocaval Shunt Provides Superior Intraoperative Hemodynamics and Reduces Blood Loss and Duration of Surgery in Live Donor Liver Transplantation: A Randomized Control Trial.

OBJECTIVE: To compare intraoperative hemodynamic parameters, blood loss, renal function, and duration of surgery with and without temporary portocaval shunt (TPCS) in live donor liver transplantation (LT) recipients. Secondary objectives were postoperative early graft dysfunction, morbidity, mortality, total intensive care unit, and hospital stay. BACKGROUND: Blood loss during recipient hepatectomy for LT remains a major concern. Routine use of TPCS during LT is not yet elucidated. METHODS: This study is a single-center, open-label, randomized control trial. The sample size was calculated based on intraoperative blood loss. After exclusion, a total of 60 patients, 30 in each arm (TPCS vs no TPCS) were recruited in the trial. RESULTS: The baseline recipient and donor characteristics were comparable between the groups. The median intraoperative blood loss ( P = 0.004) and blood product transfusions ( P < 0.05) were significantly less in the TPCS group. The TPCS group had significantly improved intraoperative hemodynamics in the anhepatic phase as compared with the no TPCS group ( P < 0.0001), requiring significantly less vasopressor support. This led to significantly better renal function as evidenced by higher intraoperative urine output in the TPCS group ( P = 0.002). Because of technical simplicity, the TPCS group had significantly fewer inferior vena cava injuries (3.3 vs 26.7%, P = 0.026) and substantially shorter hepatectomy time and total duration of surgery (529.4 ± 35.54 vs 606.83 ± 48.13 min, P < 0.0001). The time taken for normalization of lactate in the immediate postoperative period was significantly shorter in the TPCS group (median, 6 vs 13 h; P = 0.04). Although postoperative endotoxemia, major morbidity, 90-day mortality, total intensive care unit, and hospital stay were comparable between both groups, tolerance to enteral feed was earlier in the TPCS group. CONCLUSIONS: In live donor LT, TPCS is a simple and effective technique that provides superior intraoperative hemodynamics and reduces blood loss and duration of surgery.

Prolonged Anhepatic State as a Bridge to Retransplantation: A Challenging Case of a 35-Year-Old Male Liver Transplant Patient with a Temporary Portacaval Shunt.

BACKGROUND Liver transplantation is a life-saving intervention for patients with a diagnosis of acute liver failure or end-stage liver disease. Despite advances in surgical techniques and immunosuppressive therapies, primary nonfunction remains a concern, often necessitating retransplantation. In these scenarios, the anhepatic state, achieved through total hepatectomy with a temporary portacaval shunt, serves as a bridge to retransplantation. However, the challenge lies in the uncertain survival period and several potential complications associated with this procedure. CASE REPORT We present a case of a 35-year-old male patient with autoimmune hepatitis who underwent liver transplantation from a deceased donor. Seven days later, he experienced acute liver failure, leading to an urgent listing for retransplantation. To prevent the intense systemic inflammatory response, the patient underwent a total hepatectomy with a temporary portacaval shunt while awaiting another graft and endured a 57-h anhepatic state. On day 17 following retransplantation, he had cerebral death due to a hemorrhagic stroke. CONCLUSIONS This case underscores one of the most prolonged periods of anhepatic state as a bridge to retransplantation, highlighting the complexities associated with this technique. The challenges include sepsis, hypotension, coagulopathy, metabolic acidosis, renal failure, electrolyte disturbances, hypoglycemia, and hypothermia. Vigilant monitoring and careful management are crucial to improve patient outcomes. Further research is needed to optimize the duration of the anhepatic state and minimize complications for liver transplantation recipients.

Development of a Simple and Active Shunt System in the Anhepatic Stage for Surgical Training of Orthotopic Liver Transplantation.

BACKGROUND: A pig model has been commonly used for technical training for clinical liver transplantation (LT). However, as the healthy pigs have no shunt bypassing the portal vein (PV), it is necessary to complete LT within 30 minutes after shutting off the PV flow. While a model that uses an ex vivo shunt system has been used to alleviate the constraints of the anhepatic phase, it has been often difficult to keep sufficient blood flow rate and prevent the intestinal congestion because the blood vessels were occluded easily with the suction pressure by using the conventional shunt system. METHODS: We designed a portable shunt system and a novel connector that can prevent the blood vessel from occluding. The system can separately control the flow rate of PV and inferior vena cava (IVC) and detect whether the blood vessels were occluded. By reducing the solution volume in the circuit, the effected blood loss ex vivo could be minimized. The stability of this system was verified with 15 medical doctors in an advanced medical professional education course. RESULTS: The system enabled the blood flow to maintain ≥ 20 mL/minute and prevented the intestinal congestion. The perioperative hemodynamics of the recipient were stable without a blood transfusion using 25 to 40 kg pigs. We confirmed that all LT training were completed, even 60 minutes after shutting off the PV flow. CONCLUSIONS: Our system greatly contributed to training on LT for conducting the survival experiments.

Intraoperative Temporary Portocaval Shunt in Liver Transplant.

BACKGROUND: Intraoperative temporary portocaval shunt (TPCS) has been performed during liver transplant to improve hemodynamics and renal function as well as to decrease bleeding during hepatectomy. The aim of this study was to evaluate the impact of TPCS on liver transplant in a long-term single-center study. METHODS: From January 2006 to December 2018, all deceased donor transplants were retrospectively evaluated. Patients were divided in 2 groups: group 1, including those in whom intraoperative TPCS was performed and group 2, including those without TPCS. We analyzed recipient characteristics, survival, mortality, and complication rates in the intraoperative and postoperative periods. RESULTS: A total of 999 deceased donor liver transplants were studied, with 509 patients in group 1 and 490 in group 2. There were 156 cases (15.61%) of preoperative portal vein thrombosis in the whole series. Postoperative renal function (P = .029) as well as length of hospital and intensive care unit stay (P = .0001) were better in group 1. Surgery time and warm ischemia time was also shorter in group 1 (P = .0001). Complications with Clavien-Dindo score ≥ 3 were higher in group 2 (P = .006). Multivariate analysis showed important risk with fulminant hepatitis (odds ratio, 2.127; 95% CI, 1.408-3.213; P < .0001) and Model for End-Stage Liver Disease > 29 (odds ratio, 2.492; 95% CI, 1.862-3.336; P < .0001). Overall survival in group 1 at 1, 5, and 10 years were 78%, 70%, and 68%, respectively. In group 2, they were 70%, 60%, and 58%, respectively (P = .027). CONCLUSIONS: Patients who underwent intraoperative TPCS presented better postoperative renal function, less intraoperative blending, shorter surgical and warm ischemia time, shorter length of hospital and intensive care unit stay, and better overall survival after transplant. Moreover, TPCS should be used patients with severe conditions, such as fulminant hepatitis and Model for End-Stage Liver Disease score > 29.

Protective Role of the Portocaval Shunt in Liver Transplantation.

BACKGROUND: Advances in medical management and surgical technique have resulted in stepwise improvements in early post-transplant survival rates. Modifications in the surgical technique, such as the realization of the portocaval shunt (PCS), could influence survival rates. The aim of this study was to evaluate the mortality rate for 12 months after liver transplantation, analyzing the causes and risk factors related to its development and assessing the impact that PCS could have on them. METHODS: A total of 231 recipients were included in the retrospective, longitudinal, and nonrandomized study. RESULTS: The overall survival of the transplant was 85.2% (197 patients). The most frequent cause of death was infection (38.2%), followed by the multiorgan failure of multiple etiology (23.5%). Most of the risk factors related to mortality correspond to variables of the postoperative period. The results of the multivariate analysis identified the main risk factors for death: the presence of surgical complications and the need for renal replacement therapy. In contrast, the performance of PCS exerted a protective effect, reducing the probability of death by 70%. CONCLUSIONS: Despite the good results obtained in several studies, there is still debate regarding the benefit of its realization. In our study, PCS was a factor associated with a reduction in mortality, with a markedly lower probability of adverse events. However, we agree with other authors on the need for larger and randomized studies to adequately determine the validity of such results.

Ex vivo resection and temporary portocaval shunt of unresectable hepatocellular carcinoma followed by autotransplantation of liver: a case report.

BACKGROUND: Ex situ liver resection and autotransplantation is among the most advanced techniques which has been introduced in recent years. CASE PRESENTATION: A 24-year-old male referred with chief complaints of abdominal pain, nausea, and vomiting from 1 month prior to admission. Computed tomography showed a large liver mass in the left lobe of the liver with involvement of retrohepatic inferior vena cava (IVC), in favor of hepatocellular carcinoma. After hepatectomy, the common bile duct was completely removed. A 4-cm Dacron graft was anastomosed to the inferior and top of the IVC. A temporary portocaval shunt was placed, and ex situ resection of the left lobe of the liver was done. Remnant of the liver was implanted. Reconstruction of the bile duct was done using a Roux-en-Y technique, and autotransplantation of the liver was then completed. During a 4-year follow-up, the patient had no complaints and is in good conditions. CONCLUSION: With appropriate consideration of patients, despite surgical complexities, ex situ resection of unresectable HCC can provide excellent prognosis.

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

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.

Temporary Right Portocaval Shunt During Piggyback Liver Transplantation.

BACKGROUND: During piggyback liver transplantation (LT), a temporary end-to-side portocaval anastomosis (PCA) facilitates native total hepatectomy while maintaining hemodynamic stability. Some argue that PCA, performed on the main portal trunk (PT), might shorten the main portal vein and could cause technical difficulties during LT. We describe a temporary PCA performed on the right portal vein (R-PCA). METHODS: The technique entails complete dissection of the main portal trunk up its right and left branches. After having ligated the left portal vein, the right is anastomosed end-to-side to the anterior face of the inferior vena cava. Taken down of R-PCA, before graft-recipient portal vein anastomosis, is achieved by stapling or suturing. RESULTS: An R-PCA has been performed in 14 over 15 planned procedures at our unit. In one case, because of intraoperative difficulties the PCA was performed on the PT. CONCLUSIONS: A temporary R-PCA represents a feasible alternative method of portal decompression during LT. Its use can be implemented into the technical armamentarium of transplant surgeons.

Magnetic Anastomosis Rings to Create Portacaval Shunt in a Canine Model of Portal Hypertension.

PURPOSE: This study evaluated a novel magnetic compression technique (magnamosis) for creating a portacaval shunt in a canine model of portal hypertension, relative to traditional manual suture. METHODS: Portal hypertension was induced in 18 dogs by partial ligation of the portal vein (baseline). Six weeks later, extrahepatic portacaval shunt implantation was performed with either magnetic anastomosis rings, or traditional manual suture (n = 9, each). The two groups were compared for operative time, portal vein pressure, and serum biochemical indices. Twenty-four weeks post-implantation, the established anastomoses were evaluated by color Doppler imaging, venography, and gross and microscopic histological examinations. RESULTS: Anastomotic leakage did not occur in either group. The operative time to complete the anastomosis for magnamosis (4.12 ± 1.04 min) was significantly less than that needed for manual suture (24.47 ± 4.89 min, P < 0.01). The portal vein pressure in the magnamosis group was more stable than that in the manual suture group. The blood ammonia level at the end of the 24-week post-implantation observation period was significantly lower in the magnamosis group than in the manual suture group. Gross and microscopic histological examinations revealed that better smoothness and continuity of the vascular intima had been achieved via magnamosis than with manual suture. CONCLUSION: Magnamosis was superior to manual suture for the creation of a portacaval shunt in this canine model of portal hypertension.

Technical Aspects of Orthotopic Liver Transplantation-a Survey-Based Study Within the Eurotransplant, Swisstransplant, Scandiatransplant, and British Transplantation Society Networks.

BACKGROUND: Orthotopic liver transplantation (OLT) has emerged as the mainstay of treatment for end-stage liver disease. However, technical aspects of OLT are still subject of ongoing debate and are widely based on personal experience and local institutional protocols. METHODS: An international online survey was sent out to all liver transplant centers (n = 52) within the Eurotransplant, Swisstransplant, Scandiatransplant, and British Transplant Society networks. The survey sought information on center-specific OLT caseload, vascular and biliary reconstruction, graft reperfusion, intraoperative control of hemodynamics, and drain policies. RESULTS: Forty-two centers gave a valid response (81%). Out of these, 50% reported piggy-back and 40.5% total caval replacement as their standard technique. While 48% of all centers generally do not apply veno-venous bypass (vvBP) or temporary portocaval shunt (PCS) during OLT, vvBP/PCS are routinely used in six centers (14%). Portal vein first reperfusion is used in 64%, followed by simultaneous (17%), and retrograde reperfusion (12%). End-to-end duct-to-duct anastomosis without biliary drain (67%) is the most frequently performed method of biliary reconstruction. No significant associations were found between the center caseload and the surgical approach used. The predominant part of the centers (88%) stated that techniques of OLT are not evidence-based and 98% would participate in multicenter clinical trials on these topics. CONCLUSION: Technical aspects of OLT vary widely among European centers. The extent to which center-specific variation of techniques affect transplant outcomes in Europe should be elucidated further in prospective multicenter trials.

Passive mesenterico-saphenous shunt: An alternative to portocaval anastomosis for tailored portal decompression during liver transplantation.

BACKGROUND: Temporary portocaval shunt has a positive impact on short-term outcomes after liver transplantation. An alternative to temporary portocaval shunt is a distal passive decompression through mesenterico-saphenous shunt. The purpose of this study was to compare outcomes of these two types of surgical portosystemic shunt and discuss their respective place during the anhepatic phase. METHODS: Patients transplanted with portal decompression during a 4-year period were included. Patients were compared according to two types of surgical decompression techniques: temporary portocaval shunt (n = 44) and mesenterico-saphenous shunt (n = 77). Spontaneous >5-mm portosystemic shunts were described as absent, nonpersistent, distal, or proximal. Intraoperative portal pressure variations and inhospital course were compared between the two groups, with special attention on the impact of competing spontaneous and surgical shunts. RESULTS: Mesenterico-saphenous shunt and temporary portocaval shunt showed a comparable hemodynamic efficiency, with no significant difference in terms of portal pressure variations. We found no significant difference in terms of reperfusion syndrome (P = .956), transfusion rate (P = .575), renal failure (P = .239) nor early allograft dysfunction (P = .976). There was a significantly higher risk of early allograft dysfunction when competing surgical and spontaneous shunts were used (P = .002) with a lesser hemodynamic efficiency (analysis of variance test; P = .04). CONCLUSION: Portacaval or mesenterico-saphenous shunts offer similar hemodynamic efficiency without impacting the outcomes after liver transplantation. Their respective place and the place of portal decompression should be discussed regarding the presence of portal thrombosis and pre-existing portosystemic shunts. Evaluation of the anatomy and the efficiency of these shunts may guide tailored portal decompression.

Pediatric Budd-Chiari Syndrome: A Case Series.

OBJECTIVE: To study the diagnostic methods and treatment outcomes in children with Budd- Chiari syndrome. METHODS: Case records of 25 patients with Budd-Chiari syndrome were evaluated retrospectively. These patients were investigated with imaging techniques and underwent balloon angioplasty or surgical management. RESULTS: 21 patients underwent balloon angioplasty, of which 17 had good medium- to long-term results, while only one out of four patients who underwent a portocaval shunt survived. CONCLUSIONS: The balloon angioplasty has satisfactory outcome in the treatment of acute Budd-Chiari syndrome. In failed cases, the surgical therapy may be attempted, but the outcomes do not appear rewarding.

Allograft Portacaval Shunt in Small-for-Size Liver in Deceased Donor Liver Transplant.

Portal hyperperfusion is detrimental to small-for-size livers (SFSLs) in liver transplantation. Surgical techniques modulating portal inflow provide the most effective approach to protect the SFSL. In this report, we describe a technique creating an allograft portacaval shunt that effectively attenuates portal inflow without a requirement of extensive surgical dissection in the recipient during the transplantation.

Shunt intrahepático portocava en paciente con quiste hidatídico que comprime vena cava inferior / An intrahepatic cavoportal collateral pathway due to a liver hydatid cyst obstructing the inferior vena cava

No disponible

Portosystemic collaterals in living donor liver transplantation: What is all the fuss about?

Portosystemic collaterals are a common finding in patients with cirrhosis undergoing liver transplantation. Recently, there has been a renewed interest regarding their significance in the setting of living donor liver transplantation (LDLT) due to concerns of graft hypoperfusion or hyperperfusion and its impact on early posttransplant outcomes. Presence of these collaterals has greater significance in the LDLT setting when compared with the deceased donor liver transplantation setting as dictated by the difference in the physiology of partial liver grafts. We discuss current thinking of portal flow dynamics and the techniques for dealing with this clinical problem. Liver Transplantation 23 537-544 2017 AASLD.

Graft inflow modulation in adult-to-adult living donor liver transplantation: A systematic review.

INTRODUCTION: Small-for-size syndrome (SFSS) has an incidence between 0 and 43% in small-for-size graft (SFSG) adult living donor liver transplantation (LDLT). Portal hypertension following reperfusion and the hyperdynamic splanchnic state are reported as the major triggering factors of SFSS. Intra- and postoperative strategies to prevent or to reduce its onset are still under debate. We analyzed graft inflow modulation (GIM) during adult LDLT considering the indications, efficacy of the available techniques, changes in hemodynamics and outcomes. MATERIALS AND METHODS: A systematic literature search was performed using PubMed, EMBASE, Scopus and the Cochrane Library Central. Treatment outcomes including in-hospital mortality and morbidity, re-transplantation rate, 1-, 3-, and 5-year patient overall survival and 1-, 3-, and 5-year graft survival rates, hepatic artery and portal vein flows and pressures before and after inflow modulation were analyzed. RESULTS: From 563 articles, 12 studies dated between 2003 and 2014 fulfilled the selection criteria and were therefore included in the study. These comprised a total of 449 adult patients who underwent inflow modulation during adult-to-adult LDLT. Types of GIM described were splenic artery ligation, splenectomy, meso-caval shunt, spleno-renal shunt, portocaval shunt, and splenic artery embolization. Mortality and morbidity ranged between 0 and 33% and 17% and 70%, respectively. Re-transplantation rates ranged between 0% and 25%. GIM was associated with good survival for both graft and recipients, reaching an 84% actuarial rate at 5 years. Through the use of GIM, irrespective of the technique, a statistically significant reduction of PVF and PVP was obtained. CONCLUSIONS: GIM is a safe and efficient technique to avoid or limit portal hyperperfusion, especially in cases of SFSG, decreasing overall morbidity and improving outcomes.

Benefits of temporary portocaval shunt during orthotopic liver transplantation with vena cava preservation: A propensity score analysis.

During orthotopic liver transplantation (OLT), clamping of the portal vein induces splanchnic venous congestion and accumulation of noxious compounds. These adverse effects could increase ischemia/reperfusion injury and subsequently the risk of graft dysfunction, especially for grafts harvested from extended criteria donors (ECDs). Temporary portocaval shunt (TPCS) could prevent these complications. Between 2002 and 2013, all OLTs performed in our center were retrospectively analyzed and a propensity score matching analysis was used to compare the effect of TPCS in 686 patients (343 in each group). Patients in the TPCS group required fewer intraoperative transfusions (median number of packed red blood cells-5 versus 6; P = 0.02; median number of fresh frozen plasma-5 versus 6; P = 0.02); had improvement of postoperative biological parameters (prothrombin time, Factor V, international normalized ratio, alkaline phosphatase, and gamma-glutamyltransferase levels); and showed significant reduction of biliary complications (4.7% versus 10.2%; P = 0.006). Survival analysis revealed that TPCS improved 3-month graft survival (94.2% versus 88.6%; P = 0.01) as well as longterm survival of elderly (ie, age > 70 years) donor grafts (P = 0.02). In conclusion, the use of TPCS should be recommended especially when considering an ECD graft. Liver Transplantation 23 174-183 2017 AASLD.