Minimally-invasive liver resection in pediatric patients: initial experience and outcomes.

BACKGROUND: Minimally Invasive Liver Resection (MILR) is an evolving procedure in the adult population for benign and malignant lesions, offering less morbidity while maintaining acceptable outcomes. However, there lacks a published MILR experience in the pediatric population besides case reports. This report describes a pediatric MILR experience in terms of pathology, clinical specifics, and patient outcomes. METHODS: This is a retrospective review of 36 pediatric patients undergoing MILR for benign and malignant conditions. MILR was performed by pure laparoscopy, hand-assisted laparoscopy, and a hybrid laparoscopic assisted method. Data points reviewed include patient demographics, pathology, operative technique, complications, and recurrence. RESULTS: Patients with benign (15) and malignant (21) conditions underwent segmentectomy, sectionectomy, or hemihepatectomy by MILR. Thirty-one were completed with pure laparoscopy and 20 underwent hemihepatectomy. Operative time and blood loss correlated with magnitude of resection with five patients requiring a blood transfusion. Complications were minor and included a seroma, port infection, port dehiscence, line infection, and hypertrophic scar. At median follow-up of 12 months (range 6-36 months), there were no mortalities, re-operations, or recurrences. DISCUSSION: MILR can be performed in pediatric patients for benign and malignant conditions with good technical and oncologic outcomes and low morbidity.

Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka.

The use of laparoscopy for liver surgery is increasing rapidly. The Second International Consensus Conference on Laparoscopic Liver Resections (LLR) was held in Morioka, Japan, from October 4 to 6, 2014 to evaluate the current status of laparoscopic liver surgery and to provide recommendations to aid its future development. Seventeen questions were addressed. The first 7 questions focused on outcomes that reflect the benefits and risks of LLR. These questions were addressed using the Zurich-Danish consensus conference model in which the literature and expert opinion were weighed by a 9-member jury, who evaluated LLR outcomes using GRADE and a list of comparators. The jury also graded LLRs by the Balliol Classification of IDEAL. The jury concluded that MINOR LLRs had become standard practice (IDEAL 3) and that MAJOR liver resections were still innovative procedures in the exploration phase (IDEAL 2b). Continued cautious introduction of MAJOR LLRs was recommended. All of the evidence available for scrutiny was of LOW quality by GRADE, which prompted the recommendation for higher quality evaluative studies. The last 10 questions focused on technical questions and the recommendations were based on literature review and expert panel opinion. Recommendations were made regarding preoperative evaluation, bleeding controls, transection methods, anatomic approaches, and equipment. Both experts and jury recognized the need for a formal structure of education for those interested in performing major laparoscopic LLR because of the steep learning curve.

The international position on laparoscopic liver surgery: The Louisville Statement, 2008.

OBJECTIVE: To summarize the current world position on laparoscopic liver surgery. SUMMARY BACKGROUND DATA: Multiple series have reported on the safety and efficacy of laparoscopic liver surgery. Small and medium sized procedures have become commonplace in many centers, while major laparoscopic liver resections have been performed with efficacy and safety equaling open surgery in highly specialized centers. Although the field has begun to expand rapidly, no consensus meeting has been convened to discuss the evolving field of laparoscopic liver surgery. METHODS: On November 7 to 8, 2008, 45 experts in hepatobiliary surgery were invited to participate in a consensus conference convened in Louisville, KY, US. In addition, over 300 attendees were present from 5 continents. The conference was divided into sessions, with 2 moderators assigned to each, so as to stimulate discussion and highlight controversies. The format of the meeting varied from formal presentation of experiential data to expert opinion debates. Written and video records of the presentations were produced. Specific areas of discussion included indications for surgery, patient selection, surgical techniques, complications, patient safety, and surgeon training. RESULTS: The consensus conference used the terms pure laparoscopy, hand-assisted laparoscopy, and the hybrid technique to define laparoscopic liver procedures. Currently acceptable indications for laparoscopic liver resection are patients with solitary lesions, 5 cm or less, located in liver segments 2 to 6. The laparoscopic approach to left lateral sectionectomy should be considered standard practice. Although all types of liver resection can be performed laparoscopically, major liver resections (eg, right or left hepatectomies) should be reserved for experienced surgeons facile with more advanced laparoscopic hepatic resections. Conversion should be performed for difficult resections requiring extended operating times, and for patient safety, and should be considered prudent surgical practice rather than failure. In emergent situations, efforts should be made to control bleeding before converting to a formal open approach. Utilization of a hand assist or hybrid technique may be faster, safer, and more efficacious. Indications for surgery for benign hepatic lesions should not be widened simply because the surgery can be done laparoscopically. Although data presented on colorectal metastases did not reveal an adverse effect of the laparoscopic approach on oncological outcomes in terms of margins or survival, adequacy of margins and ability to detect occult lesions are concerns. The pure laparoscopic technique of left lateral sectionectomy was used for adult to child donation while the hybrid approach has been the only one reported to date in the case of adult to adult right lobe donation. Laparoscopic liver surgery has not been tested by controlled trials for efficacy or safety. A prospective randomized trial appears to be logistically prohibitive; however, an international registry should be initiated to document the role and safety of laparoscopic liver resection. CONCLUSIONS: Laparoscopic liver surgery is a safe and effective approach to the management of surgical liver disease in the hands of trained surgeons with experience in hepatobiliary and laparoscopic surgery. National and international societies, as well as governing boards, should become involved in the goal of establishing training standards and credentialing, to ensure consistent standards and clinical outcomes.

Donor morbidity after living donation for liver transplantation.

BACKGROUND & AIMS: Reports of complications among adult right hepatic lobe donors have been limited to single centers. The rate and severity of complications in living donors were investigated in the 9-center Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). METHODS: A retrospective observational study design was used. Participants included all potential living donors evaluated between 1998 and 2003. Complication severity was graded using the Clavien scoring system. RESULTS: Of 405 donors accepted for donation, 393 underwent donation, and 12 procedures were aborted. There were 245 donors (62%) who did not experience complications; 82 (21%) had 1 complication, and 66 (17%) had 2 or more. Complications were scored as grade 1 (minor; n = 106, 27%), grade 2 (potentially life threatening; n = 103, 26%), grade 3 (life threatening; n = 8, 2%), and grade 4 (leading to death; n = 3, 0.8%). Common complications included biliary leaks beyond postoperative day 7 (n = 36, 9%), bacterial infections (n = 49, 12%), incisional hernia (n = 22, 6%), pleural effusion requiring intervention (n = 21, 5%), neuropraxia (n = 16, 4%), reexploration (n = 12, 3%), wound infections (n = 12, 3%), and intraabdominal abscess (n = 9, 2%). Two donors developed portal vein thrombosis, and 1 had inferior vena caval thrombosis. Fifty-one (13%) donors required hospital readmission, and 14 (4%) required 2 to 5 readmissions. CONCLUSIONS: Adult living liver donation was associated with significant donor complications. Although most complications were of low-grade severity, a significant proportion were severe or life threatening. Quantification of complication risk may improve the informed consent process, perioperative planning, and donor care.

Outcomes of donor evaluation in adult-to-adult living donor liver transplantation.

UNLABELLED: The purpose of donor evaluation for adult-to-adult living donor liver transplantation (LDLT) is to discover medical conditions that could increase the donor postoperative risk of complications and to determine whether the donor can yield a suitable graft for the recipient. We report the outcomes of LDLT donor candidates evaluated in a large multicenter study of LDLT. The records of all donor candidates and their respective recipients between 1998 and 2003 were reviewed as part of the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). The outcomes of the evaluation were recorded along with demographic data on the donors and recipients. Of the 1011 donor candidates evaluated, 405 (40%) were accepted for donation. The donor characteristics associated with acceptance (P < 0.05) were younger age, lower body mass index, and biological or spousal relationship to the recipient. Recipient characteristics associated with donor acceptance were younger age, lower Model for End-stage Liver Disease score, and shorter time from listing to first donor evaluation. Other predictors of donor acceptance included earlier year of evaluation and transplant center. CONCLUSION: Both donor and recipient features appear to affect acceptance for LDLT. These findings may aid the donor evaluation process and allow an objective assessment of the likelihood of donor candidate acceptance.

Laparoscopic liver surgery for everyone: the hybrid method.

Minimally invasive techniques have been described recently for liver resections. We have developed a surgical approach to liver resection that combines the benefits of minimally invasive surgery with the safety of open liver resection. We have applied this hybrid approach to selected cases, and we feel that it can be adopted by most hepatobiliary surgeons, even those with minimal or no laparoscopic experience. Briefly, this technique consists of laparoscopic mobilization of the target liver lobe, followed by standard open liver resection through the extraction site. The required incisions parallel those needed for hand-assisted laparoscopic liver resections. We have compared these hybrid procedures with contemporaneous laparoscopic, hand-assisted, and open liver resections at our institution and have found that they compare favorably with minimally invasive procedures. A wider utilization of this approach by both general and hepatobiliary surgeons will result in a more generalized acceptance of minimally invasive liver resection that ultimately will advance the field and benefit patients in need of liver surgery.

Liver graft volume estimation in 100 living donors: measure twice, cut once.

Estimation of graft volume (GV) is critical in living donor liver transplantation. This study examines the accuracy of formula-derived GV estimates and compares them to both radiogically-derived estimates and actual measurements. We first compared formula-derived estimates of GV and compared them to actual volumes to provide estimates for both right lobe (RL) and left lateral segment (LLS) GV. We then applied these formulae to a validation cohort. Finally, we evaluated both formula-derived and radiologically-derived estimates by comparing them to actual GV measurements. There is a marginal concordance between formula-derived calculation and GV for RL donors, but the error ratio was lower than for radiologic estimates. In contrast, MRI measurements for LLS grafts demonstrated a lower error ratio than formula-derived estimation. Formula-derived estimates of GV should be routinely used in the initial screening of potential living donors as long as their limitations are appreciated.

Approaches to laparoscopic liver resection: a meta-analysis of the role of hand-assisted laparoscopic surgery and the hybrid technique.

Laparoscopic liver resection has been established as a safe and feasible treatment option. Surgical approaches include pure laparoscopy, hand-assisted laparoscopy (HALS), and the hybrid technique. The role of these three approaches, and their superiority over open laparotomy, is not yet known. A literature review was performed using specific search phrases, relating to hand-assisted or hybrid approaches to laparoscopic liver resection. Surgical results from 18 case series (HALS, nine series; hybrid technique, nine series), each with ≥ 10 patients, were analyzed. Results indicated that HALS was associated with a mean operative time of 82-264.5 min, an estimated blood loss of 82-300 mL, and a complication rate of 3.8-27.1%. Analysis of series involving the hybrid technique indicated a mean operative time of 111-366.5 min, an estimated blood loss of 93-936 mL, and a complication rate of 3.4-23.5%. In conclusion, there is insufficient evidence to conclude that any single approach is superior to the others, although HALS and the hybrid technique are useful when dealing with difficulties associated with pure laparoscopy. Conversely, the need for these two methods, which can function as a bridge to pure laparoscopic liver resection, may be overcome with appropriate training.

Comparative analysis of live liver donation risk using a comprehensive grading system for severity.

We investigated whether right lobe (RL) liver donation is associated with a higher incidence or severity of donor complications than left lobe (LL) liver and left lateral segment (LLS) liver donations. We studied 80 living donors: 35 RL liver donors and 45 LL/LLS liver donors. A modification of the Clavien classification was used to grade the severity of complications. RL and LL/LLS liver donations had equivalent blood loss, readmission and reoperation rates, use of blood products, and lengths of stay in the intensive care unit and hospital. RL liver donors underwent longer surgeries and experienced more postoperative pain than LL/LLS liver donors. The overall rate of complications was 33%. There was a higher rate of complications in RL liver donors (51%) than LL/LLS liver donors (20%). When graded by severity, there were more grade 2 complications in RL liver donors than in LL/LLS liver donors. Our report confirms that RL liver donation is associated with higher morbidity than LL/LLS liver donation. When the complications are systematically graded by severity, there is a significant difference in Clavien grade 2 complications in RL liver donors.

A prospective study of rapid corticosteroid elimination in simultaneous pancreas-kidney transplantation: comparison of two maintenance immunosuppression protocols: tacrolimus/mycophenolate mofetil versus tacrolimus/sirolimus.

BACKGROUND: We examined the feasibility of rapid corticosteroid elimination in simultaneous pancreas kidney transplantation. METHODS: Forty consecutive simultaneous pancreas-kidney (SPK) transplant recipients were enrolled in a prospective study in which antithymocyte globulin induction and 6 days of corticosteroids were administered along with tacrolimus and MMF (n=20) or tacrolimus and sirolimus (n=20). Mean+/-SD follow-up for recipients receiving tacrolimus/MMF and tacrolimus/sirolimus were 12.7+/-3.9 and 13.4+/-2.9 months, respectively. Patient and graft survival, and rejection rates were compared to an historical control group (n=86; mean follow-up 41.5+/-15.4 months) of SPK recipients that received induction and tacrolimus, MMF, and corticosteroids. RESULTS: Demographic characteristics of recipient and donor variables were similar among all groups. The 1-year actuarial patient, kidney, and pancreas survival rates in the 40 SPK transplant recipients with rapid corticosteroid elimination were 100, 100, and 100%, respectively. In the historical control group the 1-year actual patient, kidney, and pancreas survival rates were 96.5, 93.0, and 91.9%, respectively. The 1-year rejection-free survival rate recipients in the rapid steroid elimination group collectively was 97.5 vs 80.2% in the historical control group (P=0.034). At 6 and 12 months posttransplant the serum creatinine values remained stable in all groups. CONCLUSIONS: We conclude that chronic corticosteroid exposure is not required in SPK transplant recipients receiving antithymocyte globulin induction and maintenance immuno-suppression consisting of either tacrolimus and mycophenolate mofetil or tacrolimus and sirolimus.

Laparoscopic donor nephrectomy 1997 to 2003: lessons learned with 500 cases at a single institution.

BACKGROUND: Laparoscopic live donor nephrectomy (LDN) is a less invasive alternative to traditional open nephrectomy that has several potential advantages. However, there have been few large series reports describing the complications of LDN and the details of their management. METHODS: We performed a retrospective review of 500 LDNs performed at our center between October 1997 and September 2003. We evaluated preoperative donor characteristics, intraoperative parameters and complications, and postoperative recovery and complications. A modification of the Clavien classification was developed and used to grade the severity of all complications. RESULTS: The overall rate of intraoperative complications was 2.8%. There were 9 open conversions (1.8%), of which 6 were in the first 100 cases. Six of the 9 open conversions were for management of complications; 3 were elective. Seven renovascular incidents (1.4%) all required open conversion except one. The overall rate of postoperative complications was 3.4%. Thirty of 500 patients in our LDN series experienced an intraoperative or procedure-related complication (6.0%). When graded by severity, 18 of 31 (58.1%) of all complications were grade 1, 11 of 31 (35.4%) grade 2, and 2 of 31 (6.5%) grade 3. Only 1 recipient experienced delayed graft function, and only 1 recipient had a urologic complication. CONCLUSIONS: Our series supports the safety and efficacy of LDN with very low intraoperative complication and conversion rates. Most of the intraoperative complications can be managed laparoscopically. Readmissions are extremely rare (1.5%). Aberrant vascular anatomy and obesity are not contraindications to LDN, but they require experience. With careful surgical technique, delayed graft function and urologic complications in recipients can be avoided. A graded classification scheme for reporting complications of donor nephrectomy might be useful for maintaining registry information on donor outcomes and when informing potential donors about the risks and benefits of this procedure.

Technical and immunologic progress in simultaneous pancreas-kidney transplantation.

BACKGROUND: During the past few years the use of new immunosuppressants and refinements in surgical technique of simultaneous pancreas-kidney (SPK) transplantation have resulted in markedly improved outcomes. This is a retrospective study of 208 SPK transplants performed at Northwestern University, demonstrating the advances made at a single center that are reflective of the field at large. METHODS: An 8.5-year time span was split into 4 distinct eras marking sequential changes in immunosuppression and surgical technique that ensued. SPK transplant outcomes of patient and graft survival and rejection rates were compared. Also examined were end points related to the changing risk profile of the recipients, as well as quality of allograft function and rates of rehospitalizations. RESULTS: Recipients receiving tacrolimus/mycophenolate mofetil-based immunosuppression had patient, kidney, and pancreas survival rates significantly higher than those of earlier cohorts. The elimination of corticosteroids did not reduce survival rates or increase rejection risk. The use of pancreatic exocrine enteric drainage technique over bladder drainage reduced rehospitalizations. CONCLUSIONS: Advances in immunosuppression management combined with technical refinements have made SPK transplantation a safer and more effective treatment option for the diabetic, uremic patient.

Penetrating injuries of the subclavian artery.

BACKGROUND: Penetrating injuries of the subclavian artery occurs infrequently but represent a surgical challenge. We reviewed our experience with penetrating injury of the subclavian artery and identify factors that influenced morbidity and mortality. METHODS: A retrospective review was performed on 54 consecutive patients who sustained penetrating injury to the subclavian artery during a 10-year period. RESULTS: The causes of injuries were gunshot wounds in 46 patients (85%), stab wounds in 5 patients (9%), and shotgun wounds in 3 patients (6%). The overall mortality was 39%. Operative management of the subclavian artery injury included primary repair in 38 patients, interposition grafting in 13 patients, and ligation in 3 patients. The most common associated injury was subclavian vein (44%) followed by brachial plexus (31%). Predictors of survivability include mechanism of penetrating injuries, hemodynamic status of patients on arrival, and three or more associated injuries involving other structures. Associated brachial plexus injury accounts for the majority of long-term morbidity in survivors. CONCLUSIONS: Penetrating injuries of the subclavian artery are associated with high morbidity and mortality. Multiple concomitant injuries, unstable vital signs upon presentation, and gun shot injuries greatly increase mortality.

Does a positive pretransplant crossmatch affect long-term outcome in liver transplantation?

Despite the historical success of liver transplantation in the face of a positive lymphocytic crossmatch, increased incidence of acute cellular rejection and graft loss have been reported in this setting. Given the potential adverse effects of antirejection treatment, especially in hepatitis C virus-positive recipients, identification of predisposing factors could allow for better surveillance, avoidance of rejection, and potentially better graft outcomes.

Ureteral complications in the era of laparoscopic living donor nephrectomy: do we need to preserve the gonadal vein with the specimen?

BACKGROUND AND PURPOSE: The aim of this study was to analyze the ureteral complication rate in recipients transplanted with laparoscopically retrieved kidneys in our institution's 8-year experience when the gonal vein was not preserved with the specimen during the donor procedure. PATIENTS AND METHODS: We reviewed the records of 800 consecutive laparoscopic donor nephrectomy patients. Donor sex, age, body mass index, warm ischemia time, hospital length of stay, donor and recipient serum creatinine levels, and incidence and type of complications including the incidence of ureteral complications were recorded. RESULTS: Mean patient age was 39 +/- 10 years. Mean body mass index was 27 +/- 5. A total of 482 cases were treated purely laparoscopically. Of them, 318 were performed hand assisted. Seven hundred and ninety-three procedures were done on the left side and seven were done on the right side. The overall rate of intraoperative complications was 2.9%. The overall open conversion rate was 1.4%. The overall rate of postoperative complications was 3.9%. The postoperative day-7 serum creatinine values of the donors were 1.4 +/- 0.3 mg/dL. Mean creatinine in all patients at 1 week after transplantation was 1.5 +/- 0.2 mg/dL. We had one case of ureteral stricture in the recipients of laparoscopically procured kidneys without gonadal vein preservation technique among 800 patients. CONCLUSION: Gonadal vein preservation with the entire specimen during laparoscopic donor nephrectomy procedure is not a necessary step to protect periureteral blood supply to prevent ureteral strictures.

Evaluation of 300 minimally invasive liver resections at a single institution: less is more.

OBJECTIVE: We present the largest, most comprehensive, single center experience to date of minimally invasive liver resection (MILR). SUMMARY BACKGROUND DATA: Despite anecdotal reports of MILR, few large single center reports have examined these procedures by comparing them to their open counterparts. METHODS: Three hundred MILR were performed between July 2001 and November 2006 at our center for both benign and malignant conditions. These included 241 pure laparoscopic, 32 hand-assisted laparoscopic, and 27 laparoscopy-assisted open (hybrid) resections.These MILR were compared with 100 contemporaneous, cohort-matched open resections. MILR included segmentectomies (110), bisegmentectomies (63), left hepatectomies (47), right hepatectomies (64), extended right hepatectomies (8), and caudate lobe (8) resections. Benign etiologies encompassed cysts (70), hemangiomata (37), focal nodular hyperplasia (FNH) (23), adenomata (47), and 20 live donor right lobectomies. Malignant etiologies included primary (43) and metastatic (60) tumors. Hepatic fibrosis/cirrhosis was present in 25 of 103 patients with malignant diseases (24%). RESULTS: There was high data consistency within the 3 types of MILR. MILR compared favorably with standard open techniques: operative times (99 vs. 182 minutes), blood loss (102 vs. 325 ml), transfusion requirement (2 of 300 vs. 8 of 100), length of stay (1.9 vs. 5.4 days), overall operative complications (9.3% vs. 22%), and local malignancy recurrence (2% vs. 3%). No port-site recurrences occurred. Conversion from laparoscopic to hand-assisted laparoscopic resection occurred in 20 patients (6%), with no conversions to open. No hand-assisted procedures were converted to open, but 2 laparoscopy-assisted (7%) were converted to open. CONCLUSION: Our data show that MILR outcomes compare favorably with those of the open standard technique. Our experience suggests that MILR of varying magnitudes is safe and effective for both benign and malignant conditions.

Laparoscopic living donor nephrectomy: a single-center sequential experience comparing hand-assisted versus standard technique.

OBJECTIVES: To analyzed our institution's 8-year experience (October 1997 through March 2006) with laparoscopic donor nephrectomy (LDN) and hand-assisted LDN (HALDN), comparing donor and recipient outcomes. METHODS: A total of 482 LDNs were compared with 318 HALDNs with respect to donor sex, age, body mass index, hospital length of stay, donor and recipient serum creatinine levels, and incidence and type of complications. All HALDN were performed using hand-assist devices. RESULTS: Mean (+/-SD) ages were similar in both groups (41 +/- 10 years versus 39 +/- 10 years; P = NS). Mean body mass index was greater in the HALDN compared with the LDN group (29 +/- 5 kg/m2 versus 27 +/- 5 kg/m2; P <0.01). Hospital length of stay was longer in the LDN group (1.6 +/- 0.7 days versus 1.2 +/- 0.6 days; P <0.01). Graft function and donor's 1-week serum creatinine levels were similar (1.9 +/- 1.6 mg/dL versus 1.2 +/- 0.4 mg/dL; P = NS). The intraoperative complication rate for LDN and HALDN was 3.3% and 2.2%, respectively (P = NS). Postoperative complications occurred in 3.3% of LDNs and 4.7% of HALDNs (P = NS). The conversion rate was 1.9% for LDN and 0.6% for HALDN (P <0.01). CONCLUSIONS: Both LDN and HALDN are safe and effective. Hand-assisted LDN was not associated with an increased risk of incisional morbidity, postoperative ileus, or delayed graft function. The HALDN group experienced as uneventful and as rapid a recovery as the LDN group.

Proposed classification of complications after live donor nephrectomy.

OBJECTIVES: A standardized classification for the potential complications of living donor nephrectomy is an essential step in establishing a construct for monitoring and reporting the outcomes of this procedure. It is also helpful in informing potential donors about the inherent risks of the donor operation as part of the informed choice process. METHODS: We reviewed 600 laparoscopic live donor nephrectomies performed at our center. A modification of the Clavien classification system describing procedure-related complications was developed and used to grade the severity of all complications. RESULTS: We observed 43 complications (7.2%) in our series of 600 patients. Grade 1 defines all events that, if left untreated, would have a spontaneous resolution or needed a simple bedside procedure (39.5%). Grade 2 complications differ from grade 1 in that they are potentially life-threatening and usually require some form of intervention, but do not result in ongoing disability. We subdivided grade 2 complications (55.8% in our study) into 2a, 2b, and 2c. The latter describes complications requiring open conversion of laparoscopic donor nephrectomy for patient treatment. Grade 3 complications are events with residual or lasting disability (4.7% in our review). Grade 4 events are those resulting in renal failure or death because of any complication (none occurred in our series). CONCLUSIONS: A graded classification scheme for reporting the complications of donor nephrectomy may be useful for maintaining registry information on donor outcomes and when informing potential donors about the risks and benefits of this procedure.

Liver transplantation with simultaneous removal of an intracardiac transjugular intrahepatic portosystemic shunt and a vena cava filter without the utilization of cardiopulmonary bypass.

Transjugular intrahepatic shunts (TIPSs) are widely used in the management of portal hypertension complications including variceal bleeding, refractory ascites, and hepatic hydrothorax. Vena cava filters (VCFs) are an important therapeutic modality in the prevention of pulmonary emboli in patients suffering deep venous thrombosis and clinical contraindications for anticoagulation. Stent and filter misplacement or migration may occur, complicating liver transplantation (LT) surgery. We describe the intraoperative management of a patient with cirrhosis, who had a TIPS extending into the right atrium (RA) and a retrohepatic VCF. Stent and filter removals were deferred until the time of LT. Both procedures were performed successfully by complete cava and portal reconstruction. In conclusion, careful assessment and surgical management of patients with stent and filters permits successful LT.