Domino liver transplantation（LT）, using livers from familial amyloidotic polyneuropathy（FAP） patients, is a well described technique useful to expand donor pool. One of the main difficulties of this type of LT ari...Domino liver transplantation（LT）, using livers from familial amyloidotic polyneuropathy（FAP） patients, is a well described technique useful to expand donor pool. One of the main difficulties of this type of LT arises from the necessity to share the vascular pedicles between the graft and the donor. The most important challenge resides in restoring a proper hepatic venous outflow in the FAP-liver recipient.This is specially challenging when using the piggy-back technique, because the hepatic stumps may be too short. To overcome this issue, surgeons explored several techniques using different types of venous grafts. We describe a new technical option by using an arterial graft from the deceased donor. By using both iliac arteries a long graft is created and sutured as needed to the hepatic vein stump. We describe herein this new technique employed in a domino liver recipient who underwent retransplantation for ischemic cholangitis. The procedure was performed using the piggy-back technique; the venous stump of the FAP liver was reconstructed with the arterial graft. The patient had uneventful postoperative and mid-term hepatic function, and anastomosis was patent 24 months after LT.展开更多
AIM:To retrospectively investigate microsurgical hepatic artery(HA) reconstruction and management of hepatic thrombosis in adult-to-adult living donor liver transplantation(A-A LDLT).METHODS:From January 2001 to Septe...AIM:To retrospectively investigate microsurgical hepatic artery(HA) reconstruction and management of hepatic thrombosis in adult-to-adult living donor liver transplantation(A-A LDLT).METHODS:From January 2001 to September 2009,182 recipients with end-stage liver disease underwent A-A LDLT.Ten of these patients received dual grafts.The 157 men and 25 women had an age range of 18 to 68 years(mean age,42 years).Microsurgical techniques and running sutures with back-wall first techniques were performed in all arterial reconstructions under surgical loupes(3.5 ×) by a group of vascular surgeons.Intimal dissections were resolved by interposition of the great saphenous vein(GSV) between the donor right hepatic artery(RHA) and recipient common HA(3 cases) or abdominal aorta(AA)(2 cases),by interposition of cryopreserved iliac vessels between the donor RHA and recipient AA(2 cases).RESULTS:In the 58 incipient patients in this series,hepatic arterial thrombosis(HAT) was encountered in 4 patients,and was not observed in 124 consecutive cases(total 192 grafts,major incidence,2.08%).All cases of HAT were suspected by routine color Doppler ultrasonographic examination and confirmed by contrast-enhanced ultrasound and hepatic angiography.Of these cases of HAT,two occurred on the 1st and 7th d,respectively,following A-A LDLT,and were immediately revascularized with GSV between the graft and recipient AA.HAT in one patient occurred on the 46th postoperative day with no symptoms,and the remaining case of HAT occurred on the 3rd d following A-A LDLT,and was cured by thrombolytic therapy combined with an anticoagulant but died of multiorgan failure on the 36th d after A-A LDLT.No deaths were related to HAT.CONCLUSION:Applying microsurgical techniques and selecting an appropriate anastomotic artery for HA reconstruction are crucial in reducing the high risk of HAT during A-A LDLT.展开更多
The shortage of organs and the increasing median age of deceased donors for orthotropic liver transplantation stimulate transplant centres to accept grafts that otherwise would have been discarded due to severe vascul...The shortage of organs and the increasing median age of deceased donors for orthotropic liver transplantation stimulate transplant centres to accept grafts that otherwise would have been discarded due to severe vascular abnormali- ties. We encountered a donor with two arterial aneurysms and a left accessory hepatic artery： an arterial aneurysm of the common hepatic artery and a left accessory hepatic artery arising from a second aneurysm of the left gastric artery （Mi- chels type V）. A complex reconstruction was created to trans- plant the liver. Multiple arterial anastomosis was made and the hepatic inflow of the transplanted liver restored. Although the procedure increased the risk of hepatic artery thrombosis, one more organ supposed to be discarded was saved.展开更多
Background:The immediate challenges during microvascular reconstruction of hepatic artery(HAR)during liver transplantation(LT)can be many.Hence,in order to give a cross sectional view of these problems this study over...Background:The immediate challenges during microvascular reconstruction of hepatic artery(HAR)during liver transplantation(LT)can be many.Hence,in order to give a cross sectional view of these problems this study over a period of 1 year,showing our routine practice,was taken up.Methods:From January 2015 to December 2015,a total of 133 LTs were performed in Kaohsiung Chang Gung Memorial Hospital,Taiwan.All hepatic artery(HA)reconstructions were performed by a microvascular surgeon under an operating microscope.Results:In the 133 patients,one artery was anastomosed in 123(92.5%)patients,two in 9(6.8%)patients and three in 1(0.7%)of the patient.Eleven(8.3%)arteries were less than 2 mm in size(1–1.9 mm).There were intimal dissections(IDs)involving either the donor or the recipient arteries of mild to severe nature in 9(6.8%)patients.Immediately following graft arterial anastomosis,either there was no flow or an intraoperative hepatic artery thrombosis(HAT)was found in nine(7.1%—8 LDLT,4.8%—1 DDLT)patients.Immediate re-do anastomosis was done in all of these patients who did well in the follow-up.The overall post-operative success rate was 99.2%.One patient(0.8%)developed postoperative HAT due to infection during follow up and died due to sepsis.Conclusions:Small vessels or HA injury are the frequently encountered problems by a micro vascular surgeon.The other problems could be ID,need to do multiple reconstructions,immediate HAT and ability to re-do the HAR immediately.展开更多
Background At present, revascularization is still one of the most critical technologies in orthotopic liver transplantation （OLT）. Hepatic artery （HA） variations occur frequently in both donors and recipients. Mor...Background At present, revascularization is still one of the most critical technologies in orthotopic liver transplantation （OLT）. Hepatic artery （HA） variations occur frequently in both donors and recipients. Moreover, there are always some pathological changes in the recipient hepatic artery. If handled improperly, it may cause complications after anastomosis.Therefore, arterial conduit could be used in primary OLT, re-OLT and multiple-OLT. This study aimed to investigate the indications, methods and techniques with usage of arterial conduit for HA revascularization during adult OLT.Methods We reviewed 1200 patients of consecutive OLTs performed during 2000-2009 in the First Affiliated Hospital of Sun Yat-sen University. Of these patients, 48 recipients with artery variations received HA revascularization with usage of arterial conduit and special postoperative managements. The indications, methods, techniques, and the managements of postoperative complications in adult OLT with usage of arterial conduit for HA revascularization were analyzed.Results In 48 cases with artery bypass, the arterial conduit were anastomosed between donor hepatic artery and recipient infrarenal aorta （n=32）, between donor hepatic artery and recipient suprarenal aorta （n=10）, and between donor upper abdominal organ cluster artery and recipient suprarenal aorta （n=6）. The technique was applied in 4% （48/1200 cases） of the whole OLTs performed in the same period, and the patency rate of the conduits was 100%. Forty patients （83.3%） survived, and the average survival time was 3.9 years. Eight patients （16.7%） died （all due to tumor recurrence）,while the average survival time was 1.2 years. All these patients have not experienced artery-related complications in their survival time.Conclusions When recipient HA has variations or pathological changes in OLT, the donor artery should be anastomosed to recipient abdominal aorta with an arterial conduit to achieve satisfactory outcomes. For arterial anastomosis can not be routinely performed, donor iliac artery as a conduit to be anastomosed with the recipient abdominal aorta is safe and effective.展开更多
文摘Domino liver transplantation（LT）, using livers from familial amyloidotic polyneuropathy（FAP） patients, is a well described technique useful to expand donor pool. One of the main difficulties of this type of LT arises from the necessity to share the vascular pedicles between the graft and the donor. The most important challenge resides in restoring a proper hepatic venous outflow in the FAP-liver recipient.This is specially challenging when using the piggy-back technique, because the hepatic stumps may be too short. To overcome this issue, surgeons explored several techniques using different types of venous grafts. We describe a new technical option by using an arterial graft from the deceased donor. By using both iliac arteries a long graft is created and sutured as needed to the hepatic vein stump. We describe herein this new technique employed in a domino liver recipient who underwent retransplantation for ischemic cholangitis. The procedure was performed using the piggy-back technique; the venous stump of the FAP liver was reconstructed with the arterial graft. The patient had uneventful postoperative and mid-term hepatic function, and anastomosis was patent 24 months after LT.
文摘AIM:To retrospectively investigate microsurgical hepatic artery(HA) reconstruction and management of hepatic thrombosis in adult-to-adult living donor liver transplantation(A-A LDLT).METHODS:From January 2001 to September 2009,182 recipients with end-stage liver disease underwent A-A LDLT.Ten of these patients received dual grafts.The 157 men and 25 women had an age range of 18 to 68 years(mean age,42 years).Microsurgical techniques and running sutures with back-wall first techniques were performed in all arterial reconstructions under surgical loupes(3.5 ×) by a group of vascular surgeons.Intimal dissections were resolved by interposition of the great saphenous vein(GSV) between the donor right hepatic artery(RHA) and recipient common HA(3 cases) or abdominal aorta(AA)(2 cases),by interposition of cryopreserved iliac vessels between the donor RHA and recipient AA(2 cases).RESULTS:In the 58 incipient patients in this series,hepatic arterial thrombosis(HAT) was encountered in 4 patients,and was not observed in 124 consecutive cases(total 192 grafts,major incidence,2.08%).All cases of HAT were suspected by routine color Doppler ultrasonographic examination and confirmed by contrast-enhanced ultrasound and hepatic angiography.Of these cases of HAT,two occurred on the 1st and 7th d,respectively,following A-A LDLT,and were immediately revascularized with GSV between the graft and recipient AA.HAT in one patient occurred on the 46th postoperative day with no symptoms,and the remaining case of HAT occurred on the 3rd d following A-A LDLT,and was cured by thrombolytic therapy combined with an anticoagulant but died of multiorgan failure on the 36th d after A-A LDLT.No deaths were related to HAT.CONCLUSION:Applying microsurgical techniques and selecting an appropriate anastomotic artery for HA reconstruction are crucial in reducing the high risk of HAT during A-A LDLT.
文摘The shortage of organs and the increasing median age of deceased donors for orthotropic liver transplantation stimulate transplant centres to accept grafts that otherwise would have been discarded due to severe vascular abnormali- ties. We encountered a donor with two arterial aneurysms and a left accessory hepatic artery： an arterial aneurysm of the common hepatic artery and a left accessory hepatic artery arising from a second aneurysm of the left gastric artery （Mi- chels type V）. A complex reconstruction was created to trans- plant the liver. Multiple arterial anastomosis was made and the hepatic inflow of the transplanted liver restored. Although the procedure increased the risk of hepatic artery thrombosis, one more organ supposed to be discarded was saved.
文摘Background:The immediate challenges during microvascular reconstruction of hepatic artery(HAR)during liver transplantation(LT)can be many.Hence,in order to give a cross sectional view of these problems this study over a period of 1 year,showing our routine practice,was taken up.Methods:From January 2015 to December 2015,a total of 133 LTs were performed in Kaohsiung Chang Gung Memorial Hospital,Taiwan.All hepatic artery(HA)reconstructions were performed by a microvascular surgeon under an operating microscope.Results:In the 133 patients,one artery was anastomosed in 123(92.5%)patients,two in 9(6.8%)patients and three in 1(0.7%)of the patient.Eleven(8.3%)arteries were less than 2 mm in size(1–1.9 mm).There were intimal dissections(IDs)involving either the donor or the recipient arteries of mild to severe nature in 9(6.8%)patients.Immediately following graft arterial anastomosis,either there was no flow or an intraoperative hepatic artery thrombosis(HAT)was found in nine(7.1%—8 LDLT,4.8%—1 DDLT)patients.Immediate re-do anastomosis was done in all of these patients who did well in the follow-up.The overall post-operative success rate was 99.2%.One patient(0.8%)developed postoperative HAT due to infection during follow up and died due to sepsis.Conclusions:Small vessels or HA injury are the frequently encountered problems by a micro vascular surgeon.The other problems could be ID,need to do multiple reconstructions,immediate HAT and ability to re-do the HAR immediately.
基金This study was supported by a grant from the Guangdong Natural Science Foundation （No. 9151008901000052）.
文摘Background At present, revascularization is still one of the most critical technologies in orthotopic liver transplantation （OLT）. Hepatic artery （HA） variations occur frequently in both donors and recipients. Moreover, there are always some pathological changes in the recipient hepatic artery. If handled improperly, it may cause complications after anastomosis.Therefore, arterial conduit could be used in primary OLT, re-OLT and multiple-OLT. This study aimed to investigate the indications, methods and techniques with usage of arterial conduit for HA revascularization during adult OLT.Methods We reviewed 1200 patients of consecutive OLTs performed during 2000-2009 in the First Affiliated Hospital of Sun Yat-sen University. Of these patients, 48 recipients with artery variations received HA revascularization with usage of arterial conduit and special postoperative managements. The indications, methods, techniques, and the managements of postoperative complications in adult OLT with usage of arterial conduit for HA revascularization were analyzed.Results In 48 cases with artery bypass, the arterial conduit were anastomosed between donor hepatic artery and recipient infrarenal aorta （n=32）, between donor hepatic artery and recipient suprarenal aorta （n=10）, and between donor upper abdominal organ cluster artery and recipient suprarenal aorta （n=6）. The technique was applied in 4% （48/1200 cases） of the whole OLTs performed in the same period, and the patency rate of the conduits was 100%. Forty patients （83.3%） survived, and the average survival time was 3.9 years. Eight patients （16.7%） died （all due to tumor recurrence）,while the average survival time was 1.2 years. All these patients have not experienced artery-related complications in their survival time.Conclusions When recipient HA has variations or pathological changes in OLT, the donor artery should be anastomosed to recipient abdominal aorta with an arterial conduit to achieve satisfactory outcomes. For arterial anastomosis can not be routinely performed, donor iliac artery as a conduit to be anastomosed with the recipient abdominal aorta is safe and effective.
