Ascending aorta cannulation for isolated liver procurement in extended criteria donors: a safe option in case of massive infrarenal aortic atherosclerosis.

The chronic organ shortage and the increased number of patients on the waiting list for liver transplantation have led to a progressive increase in the use of extended criteria donors. Nowadays more and more overweight donors with several comorbidities are selected for donation providing acceptable patient and liver graft survival. These donors have often aortic atherosclerosis which can spare the hepatic artery making suitable the liver for procurement. Massive aortic atherosclerosis localized to infrarenal aorta can challenge aortic cannulation for organ cooling. We herein describe in a stepwise approach the aortic cannulation realized at the ascending aorta level in case of massive infrarenal aortic atherosclerosis in ECD donors. This technique represents a safe option when abdominal aorta is not suitable for cannulation and it should be included into the surgical armamentarium of liver transplant surgeon.

Upper Transversal Hepatectomy with Two Hepatic Veins Reconstruction: Combining Parenchymal-Sparing Liver Surgery with Transplantation Techniques for Colorectal Liver Metastases.

BACKGROUND: Colorectal liver metastases (CRLM) involving two or three main hepatic veins pose a surgical challenge. For these lesions, compelled surgical strategies have usually included major and/or extended liver resections according to the two-stage hepatectomy (TSH) strategy. More recently, a one-stage transversal hepatectomy resecting the posterosuperior liver segment (7,8,4 superior) along with one or more hepatic veins has been described, such as showed herein in a didactical video. METHODS: The patient is a 78-year-old woman with two large CRLMs located into segment 2 and into segment 8. Magnetic resonance imaging and computed tomography showed tumour stability after chemotherapy. The lesion of segment 2 is close to the left hepatic vein while the lesion of segment 8 infiltrates the middle (MHV) and the right hepatic veins (RHV). RESULTS: Under intermittent pedicular clamping, resection of the segment 7, 8, 4 superior along with the right and middle hepatic veins is performed. Reconstruction of the veins was performed with 2 cryopreserved autologous saphenous grafts. Postoperative course was uneventful and postoperative CT scan showed patency of the two venous graft reconstructions. CONCLUSIONS: Surgery for CRLM has evolved over the last two decades shifting from large anatomical resections to parenchymal-sparing resections. Sparing liver parenchyma allows surgical radicality while reducing the risk of liver failure and allowing repeated liver resection. Associating vascular reconstruction to parenchymal-sparing surgery reduces the risk of venous congestion of the spared liver parenchyma.

Augmentation Patch V-venoplasty to Correct Atretic Changes of the Portal Vein During Adult Liver Transplantation.

The development of large spontaneous portosystemic shunts (PSS) is a common finding in liver cirrhosis. The diversion of the portal flow through PSS directly into the caval system causes progressive liver atrophy and atretic changes of the portal vein. During both living and deceased donor liver transplantation (LT), persistence of large PSS has been associated to portal flow steal phenomena causing decreased patients and graft survival. Atretic changes of the portal vein and large PSS often coexist potentially representing a technical challenge during portal vein reconstruction. We herein describe (with a didactical video) an easy augmentation patch V-venoplasty used in the presence of atretic changes of the portal vein LT.

Liver procurement: the counterclockwise technique step-by-step with video.

BACKGROUND: The availability of videos of different procedures is certainly contributing to the diffusion and standardization of surgical procedures around the world. This didactical video article shows step-by-step a "counterclockwise" technique which we have previously described for liver procurement whenever the pancreas is not procured. METHODS: The technique entails 6 steps: the hepatic pedicle, the pancreatic neck, the superior mesenteric artery (SMA), the celiac trunk, the supraceliac aorta, and the inferior vena cava. This  technique follows a "counterclockwise" sequence around the liver. RESULTS: The routine practice with this technique at our unit showed high reproducibility while maintaining the safety of the procedure among different young fellows trained over the years. The limits of this technique are represented by the fact that is reserved to cases without pancreas procurement. CONCLUSIONS: The "counterclockwise" technique represents a valid and an easy technique to learn for liver procurement.

Temporary portal decompression during liver transplantation: a video review of the different techniques.

PURPOSE: Temporary portal decompression (TPD) during liver transplantation (LT) remains a divisive technical issue in the liver transplant community. In this video-based article, we show the technical details of the different techniques used for TPD during LT. METHODS: An early portal section, before liver mobilization, should be preferred in order to achieve hepatectomy of a totally devascularized liver. Portal decompression can be achieved through direct right portocaval shunts and indirect portosystemic shunts (i.e., mesentericosaphenous and portosaphenous shunts). RESULTS: The preference for direct portocaval or indirect portosystemic shunts is tailored on patients and anatomical characteristics. Each of these three techniques presents specific indications, limitations, and advantages. CONCLUSION: TPD during LT can be achieved through different techniques that aim to facilitate the recipient hepatectomy, reduce the blood loss, and maintain hemodynamic stability.

Misplacement of transjugular intrahepatic portosystemic shunts: A surgical challenge for liver transplantation?

BACKGROUND: The impact of transjugular intrahepatic portosystemic shunt misplacement on outcomes of liver transplantation remains controversial. We systematically reviewed the literature on the outcomes of liver transplantation with transjugular intrahepatic portosystemic shunt misplacement. METHODS: This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Cochrane library, PubMed, and Embase were searched (January 1990-April 2020) for studies reporting patients undergoing liver transplantation with transjugular intrahepatic portosystemic shunt misplacement. RESULTS: Thirty-six studies reporting 181 patients who underwent liver transplantation with transjugular intrahepatic portosystemic shunt misplacement were identified. Transjugular intrahepatic portosystemic shunt was misplaced with a variable degree of extension toward the inferior vena cava/right heart in 63 patients (34%), the spleno/portal/superior mesenteric venous confluence in 105 patients (58%), and both in 15 patients (8%). Transjugular intrahepatic portosystemic shunt thrombosis was also present in 21 cases (12%). The median interval between transjugular intrahepatic portosystemic shunt placement and liver transplantation ranged from 1 day to 6 years. Complete transjugular intrahepatic portosystemic shunt removal was successfully performed in all but 12 (7%) patients in whom part of the transjugular intrahepatic portosystemic shunt was left in situ. Cardiac surgery under cardiopulmonary bypass was necessary to remove transjugular intrahepatic portosystemic shunt from the right heart in 4 patients (2%), and a venous graft interposition was necessary for a portal anastomosis in 5 patients (3%). Postoperative mortality (90 days) was 1.1% (2 patients), and portal vein thrombosis developed postoperatively in 4 patients (2%). CONCLUSION: Misplaced transjugular intrahepatic portosystemic shunt removal is possible in most cases during liver transplantation with extremely low mortality and good postoperative outcomes. Preoperative surgical strategy and intraoperative tailored surgical technique reduces the potential consequences of transjugular intrahepatic portosystemic shunt misplacement.

Middle-segment preserving pancreatectomy for multifocal neuroendocrine pancreatic tumors.

BACKGROUND: Multifocal neuroendocrine tumors (NET) usually occur in the context of a multiple neuroendocrine neoplasia type 1 (MEN1). When the proximal part of the pancreatic body is spared by NET, Miura et al. have proposed a "middle-segment preserving" pancreatectomy (MSP) as alternative to total pancreatectomy [1-3]. VIDEO: A 28-year-old woman with MEN1 was referred for surgical resection of a multifocal pancreatic tumor with single metastasis located and a single liver metastasis in close contact with the left hepatic duct. The preoperative work-up by DOTATOC-PETSCAN revealed multifocal tumors sparing only the proximal part of the pancreatic body. Hormonal dosages were normal but Chromogranine A was elevated at 700 µg/l. At surgery pancreatic intraoperative ultrasonography confirmed the absence of tumor at the proximal part of the pancreas. A pancreaticoduodenectomy was performed first followed by a left pancreatectomy with partial splenectomy. A 3 × 5 cm remnant of the pancreatic body vascularized by a dorsal pancreatic artery was preserved (Fig. 1). A left hepatectomy was then performed (Fig. 2). Digestive reconstruction is performed by a pancreatojejunostomy with an externalized pancreatic stent (Fig. 3), hepaticojejunostomy and a gastrojejunal anastomosis. RESULTS: Surgery lasted 660 minutes. Postoperative course was uneventful but a late readmission was necessary because of pyelonephritis due to nephrolithiasis treated by ureteral stent insertion. At 11 months postoperative follow-up the patient was disease-free with no endocrine dysfunction under oral pancreatic enzyme supplementation. Total weight loss since surgery was 8 Kilograms. CONCLUSIONS: A middle-segment-preserving pancreatectomy could be a valid surgical alternative to total pancreatectomy for multifocal pancreatic tumors sparing the proximal pancreatic body. This operation can achieve acceptable functional outcomes but large series with long-term follow up are needed to evaluate the advantages and results of MSP.

Hepatocellular cancer and liver transplantation: a Western experience.

Orthotopic liver transplantation is the preferred treatment option in patients with hepatocellular carcinoma developing in chronic liver disease. Unfortunately, based on classical transplantation criteria (Milan criteria), only a minority of patients with hepatocellular carcinoma are candidate to orthotopic liver transplantation. Major improvements in treatment strategy and surgical technique including the use of neoadjuvant locoregional therapies and progresses of post-transplant immunosuppressive treatment have contributed to safely expand transplantation criteria preserving acceptable surgical morbidity-mortality and good oncologic outcome. Further extension of transplantation criteria may have advantages including an increase in the number of transplant candidates and improvement of the prognosis of the disease and also disadvantages including an increase of surgical morbidity and deterioration of global oncologic outcome of orthotopic liver transplantation in hepatocellular carcinoma. In the future, identification of imaging or molecular prognostic markers could help to better define transplantation criteria.