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RANGRASS G, VANNUCCI A. Veno-venous bypass in liver transplantation: a commonly used technique with elusive outcome benefits. Minerva Anestesiol 2022; 88:538-540. [DOI: 10.23736/s0375-9393.22.16706-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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2
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Rocco G, Siniscalchi A, Serenari M, Fallani G, Germinario G, Maroni L, Prosperi E, Del Gaudio M, Odaldi F, Cescon M, Ravaioli M. Complex Liver Transplantation Using Venovenous Bypass With an Atypical Placement of the Portal Vein Cannula. Liver Transpl 2021; 27:231-235. [PMID: 37160012 DOI: 10.1002/lt.25878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/06/2020] [Accepted: 07/01/2020] [Indexed: 01/13/2023]
Abstract
In liver transplantation (LT) medical literature, venovenous bypass (VVB) with the interposition of a venous graft attached to the inferior mesenteric vein (IMV) or to the splenic vein (SV) has not been reported previously. Here, we report the decompression of the portomesenteric compartment in 2 patients with complex cases of orthotopic LT. A femoroaxillary percutaneous VVB was installed prior to abdominal opening to decompress massive collateral veins in the abdominal wall. In the first patient, the IMV was connected to a donor vein graft with a lateroterminal anastomosis, and the distal part of the vein graft was cannulated and connected to the VVB. In the second patient, because of the excessive size of the spleen, it was necessary to perform a splenectomy to gain sufficient space in the abdomen to implant the new liver. The SV was connected to a donor vein graft with a terminoterminal anastomosis, and the distal part of the vein graft was cannulated and connected to the VVB. In both patients, the decompression of the portomesenteric compartment was crucial to reduce portal hypertension and to access the hepatic hilum, where the dissection was very complex due to previous major surgeries. In conclusion, VVB with the interposition of a venous graft attached to the IMV or to the SV during LT is a safe and simple technique, and it may be useful for patients needing VVB with no standard access to the portal compartment, particularly in the case of severe portal hypertension and re-LTs.
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Affiliation(s)
- Giuseppe Rocco
- Department of General Surgery and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Alma Mater, Bologna, Italy
| | - Antonio Siniscalchi
- Department of General Surgery and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Alma Mater, Bologna, Italy
| | - Matteo Serenari
- Department of General Surgery and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Alma Mater, Bologna, Italy
| | - Guido Fallani
- Department of General Surgery and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Alma Mater, Bologna, Italy
| | - Giuliana Germinario
- Department of General Surgery and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Alma Mater, Bologna, Italy
| | - Lorenzo Maroni
- Department of General Surgery and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Alma Mater, Bologna, Italy
| | - Enrico Prosperi
- Department of General Surgery and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Alma Mater, Bologna, Italy
| | - Massimo Del Gaudio
- Department of General Surgery and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Alma Mater, Bologna, Italy
| | - Federica Odaldi
- Department of General Surgery and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Alma Mater, Bologna, Italy
| | - Matteo Cescon
- Department of General Surgery and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Alma Mater, Bologna, Italy
| | - Matteo Ravaioli
- Department of General Surgery and Transplantation, Azienda Ospedaliero-Universitaria di Bologna, Alma Mater, Bologna, Italy
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Azoulay D, Salloum C, Eshkenazi R, Shwaartz C, Lahat E, Lim C. Access to the Portal System Via the Mesentery for Establishing Venous Bypass in Liver Transplantation. Liver Transpl 2019; 25:807-810. [PMID: 30900357 DOI: 10.1002/lt.25452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 02/23/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Daniel Azoulay
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France.,Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chady Salloum
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Rony Eshkenazi
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France.,Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chaya Shwaartz
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eylon Lahat
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France.,Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chetana Lim
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
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Salloum C, Lim C, Lahat E, Compagnon P, Azoulay D. The veno-venous bypass in liver transplantation: an unfinished product. Hepatobiliary Surg Nutr 2016; 5:269-72. [PMID: 27275471 DOI: 10.21037/hbsn.2016.02.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Veno-venous bypass (VVB) using a patent para-umbilical vein during liver transplantation (LT) has not been reported previously. Here, we report the decompression of the porto-mesenteric compartment via a patent para-umbilical vein in a patient needing a VVB during LT. Pre-transplant CT-scan showed a large patent para-umbilical vein. A femoro-axillary percutaneous VVB was installed prior to abdominal opening to decompress massive collateral veins in the abdominal wall. The para-umbilical vein was stapled and its proximal end was cannulated and connected to the VVB. The severe atrophy of the native liver allowed to place the whole liver graft in the "liver fossa" while maintaining the native liver pulled toward the left side and connected to the VVB. This maneuver maintained splanchnic venous decompression during latero-lateral cavo-caval anastomosis. The "portal" cannula was clamped and removed. The native portal vein was clamped and divided. Standard portal, arterial, and biliary reconstructions were then performed. A patent para-umbilical vein, present in one third of patients with portal hypertension could be used whenever VVB is indicated during LT in this setting.
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Affiliation(s)
- Chady Salloum
- 1 Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor Hospital, Créteil, France ; 2 INSERM U965, Paris, France ; 3 INSERM U955, Créteil, France
| | - Chetana Lim
- 1 Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor Hospital, Créteil, France ; 2 INSERM U965, Paris, France ; 3 INSERM U955, Créteil, France
| | - Eylon Lahat
- 1 Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor Hospital, Créteil, France ; 2 INSERM U965, Paris, France ; 3 INSERM U955, Créteil, France
| | - Philippe Compagnon
- 1 Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor Hospital, Créteil, France ; 2 INSERM U965, Paris, France ; 3 INSERM U955, Créteil, France
| | - Daniel Azoulay
- 1 Department of Hepato-Pancreato-Biliary and Liver Transplantation, Henri Mondor Hospital, Créteil, France ; 2 INSERM U965, Paris, France ; 3 INSERM U955, Créteil, France
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Complex Liver Resection Using Standard Total Vascular Exclusion, Venovenous Bypass, and In Situ Hypothermic Portal Perfusion. Ann Surg 2015; 262:93-104. [DOI: 10.1097/sla.0000000000000787] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Azoulay D, Pascal G, Salloum C, Adam R, Castaing D, Tranecol N. Vascular reconstruction combined with liver resection for malignant tumours. Br J Surg 2014; 100:1764-75. [PMID: 24227362 DOI: 10.1002/bjs.9295] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND The resectability criteria for malignant liver tumours have expanded during the past two decades. The use of vascular reconstruction after hepatectomy has been integral in this process. However, the majority of reports are anecdotal. This is a retrospective analysis of the techniques, morbidity, mortality and risk factors of liver resections with vascular reconstruction based on a large series from a single centre. METHODS Patients who underwent hepatic resection combined with vascular resection and reconstruction between 1997 and 2009 were included in this study. Indications for surgery, morbidity and 90-day mortality are reported along with factors predictive of operative mortality. RESULTS Eighty-four patients had liver resection with 97 vascular resections and reconstruction. There were 44 men and 40 women with a mean(s.d.) age of 56·9(12·1) years. Mean(s.d.) follow-up was 37·3(34·1) months. All patients had primary or metastatic liver tumours. The perioperative morbidity rate was 62 per cent (52 patients) and the operative mortality rate 14 per cent (12). Predictors of operative mortality were: bilirubin level exceeding 34 µmol/ml (P = 0·023), indocyanine green retention rate at 15 min over 10 per cent (P = 0·031), duration of ischaemia (P = 0·011), amount of blood transfused (P = 0·025) and combined major extrahepatic procedure (P = 0·042). Actuarial 3- and 5-year survival rates were 44 and 26 per cent respectively. CONCLUSION Liver resection with combined vascular resection and reconstruction can be performed in selected patients with acceptable morbidity and mortality. The lack of therapeutic alternatives and the poor outcome of non-operative management seem to justify this approach. The identification of risk factors should help improve patient selection and postoperative outcome as well as facilitate objective risk communication with surgical candidates.
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Affiliation(s)
- D Azoulay
- Centre Hépato-Biliaire, Département de Chirurgie Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris (AP-HP) Hôpital Paul Brousse, Villejuif; Service de Chirurgie Hépato-Bilio-Pancreatique, AP-HP Hôpital Henri Mondor, Créteil, France
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Lu SY, Matsusaki T, Abuelkasem E, Sturdevant ML, Humar A, Hilmi IA, Planinsic RM, Sakai T. Complications related to invasive hemodynamic monitors during adult liver transplantation. Clin Transplant 2013; 27:823-8. [PMID: 24033433 DOI: 10.1111/ctr.12222] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2013] [Indexed: 01/10/2023]
Abstract
The rate of complications directly related to invasive monitors during liver transplantation (LT) was reviewed in 1206 consecutive adult LTs performed over 8.6 yr (1/1/2004-7/31/2012). The designated anesthesiologists placed intra-operative monitors, including two arterial catheters (via the radial and the right femoral arteries), central venous catheters (a 9 Fr. catheter and an 18 Fr. veno-venous bypass [VVB] return cannula in an internal jugular vein), a pulmonary artery catheter, and a transesophageal echocardiography (TEE) probe. A 17 Fr. VVB drainage cannula was placed via the left femoral vein. No Clavien-Dindo Grade V (death) or Grade IV (organ dysfunction) complication was identified. Nine Grade III complications (requiring surgical intervention) and 15 Grade II complications (conservative treatment) were noted. Seven (0.58% in 1206 cases) were related to a femoral arterial line with Grade III of four; seven (0.58%) were due to VVB return cannula in the femoral vein with Grade III of one; four (0.33%) were related to central venous catheters with Grade III of two; four (0.33%) were due to a TEE probe with Grade III of two; and two minor complications (0.17%) that were related to a radial arterial line. No complication was observed with a pulmonary arterial catheter. Current invasive monitors placed during LT have an acceptable risk.
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Affiliation(s)
- Shu Y Lu
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Tincani G, Hoti E, Andreani P, Ricca L, Pittau G, Vitale V, Blandin F, Adam R, Castaing D, Azoulay D. Operative risks of domino liver transplantation for the familial amyloid polyneuropathy liver donor and recipient: a double analysis. Am J Transplant 2011; 11:759-66. [PMID: 21446978 DOI: 10.1111/j.1600-6143.2011.03477.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although domino liver transplantation (LT) is an established procedure, data about the operative risks are limited. This study aimed at evaluating the operative risks of domino LT. Two retrospective analyses were conducted (comparison of familial amyloid polyneuropathy [FAP] liver donors [61 patients] vs. FAP nondonors [39 patients] and FAP liver recipients [61 patients] vs. deceased donor liver recipients [61 patients]). First analysis showed a 60-day mortality of 6.6% for FAP donors and 7.7% for FAP nondonors (p = 1.0). No patient developed primary graft nonfunction. Acute rejection was higher in FAP nondonors compared to FAP donors (38.5% vs. 13.1%). Both groups had similar vascular and biliary complication rates. ICU stay was similar, whereas total hospitalization was longer for FAP nondonors. Both groups had similar 1- and 5-year patient and graft survival rates (83.4% vs. 87.2%, and 79.8% vs. 71.8%, p = 0.7) and (83.3% vs. 87.2%, and 79.1% vs.71.8%, p = 0.7). The second analysis showed a 1.6% mortality for FAP liver recipients vs. 3.2% of the control group (p = 1). Both groups had similar morbidity and technical complication rates (18.0% vs. 13.1%, p = 0.45) and (0.18 vs. 0.15, p = 0.65). The domino procedure does not add any risk to FAP donor or recipient. It increases the organ pool allowing transplantation of marginal recipients who otherwise are denied deceased donor liver transplantation.
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Affiliation(s)
- G Tincani
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
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Sakai T, Gligor S, Diulus J, McAffee R, Wallis Marsh J, Planinsic RM. Insertion and management of percutaneous veno-venous bypass cannula for liver transplantation: a reference for transplant anesthesiologists. Clin Transplant 2009; 24:585-91. [DOI: 10.1111/j.1399-0012.2009.01145.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Polak WG, Peeters PM, Slooff MJ. The evolution of surgical techniques in clinical liver transplantation. A review. Clin Transplant 2009; 23:546-64. [DOI: 10.1111/j.1399-0012.2009.00994.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Fonouni* H, Mehrabi * A, Soleimani M, Müller SA, Büchler MW, Schmidt J. The need for venovenous bypass in liver transplantation. HPB (Oxford) 2008; 10:196-203. [PMID: 18773054 PMCID: PMC2504375 DOI: 10.1080/13651820801953031] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Indexed: 12/12/2022]
Abstract
Since introduction of the conventional liver transplantation (CLTx) by Starzl, which was based on the resection of recipient inferior vena cava (IVC) along the liver, the procedure has undergone several refinements. Successful use of venovenous bypass (VVB) was first introduced by Shaw et al., although in recent decades there has been controversy regarding the routine use of VVB during CLTx. With development of piggyback liver transplantation (PLTx), the use of caval clamping and VVB is avoided, leading to fewer complications related to VVB. However, some authors still advocate VVB in PLTx. The great diversity among centers in their use of VVB during CLTx, or even along the PLTx technique, has led to confusion regarding the indication setting for VVB. For this reason, we present an overview of the use of VVB in CLTx, the target of patients for whom VVB could be beneficial, and the needs assessment of VVB for patients undergoing PLTx. Recent studies have shown that with the advancement of surgical skills, refinement of surgical techniques, and improvements in anesthesiology, there are only limited indications for doing CLTx with VVB routinely. PLTx with preservation of IVC can be performed in almost all primary transplants and in the majority of re-transplantations without the need for VVB. Nevertheless, in a few selective cases with severe intra-operative hemodynamic instability, or with a failed test of transient IVC occlusion, the application of VVB is still justifiable. These indications should be judged intra-operatively and the decision is based on each center's preference.
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Affiliation(s)
- Hamidreza Fonouni*
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
| | - Arianeb Mehrabi*
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
| | - Mehrdad Soleimani
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
| | - Sascha A. Müller
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
| | - Markus W. Büchler
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
| | - Jan Schmidt
- Department of General, Visceral and Transplant Surgery, University of HeidelbergGermany
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Sakai T, Planinsic RM, Hilmi IA, Marsh JW. Complications associated with percutaneous placement of venous return cannula for venovenous bypass in adult orthotopic liver transplantation. Liver Transpl 2007; 13:961-5. [PMID: 17600351 DOI: 10.1002/lt.21072] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Percutaneous large bore cannula placement during orthotopic liver transplantation (OLT) for use in venovenous bypass (VVB) has been reported to be a rapid and simple technique. It is, however, a technique that carries its own risks. The aim of the study was to investigate the incidence of complications related to the placement of a percutaneous venous return cannula and subsequent VVB in OLT. A retrospective review of 360 consecutive adult OLT patients during a period of 18 months (January 1, 2003 to June 30, 2004) was performed. The percutaneous venous cannula (18 Fr) was placed by an attending transplant anesthesiologist. The cannulation was attempted in 326 patients (90.6%). No cannulation was attempted on the subclavian veins. Internal jugular venous cannula placement was attempted but aborted in 6 patients (1.8%) due to technical difficulties. In 320 patients who received an internal jugular venous cannula, 313 (97.8%) underwent OLT without complication. The remaining 7 patients (2.2%) had complications. The operation was delayed for 1 patient due to suspected hemomediastinum. The other 6 complications were related to VVB: air embolism (2 patients), low flow rate (2 patients), hypotension (1 patient), and atrial fibrillation (1 patient). Successful OLT was eventually carried out in all the 7 patients and no mortality associated with internal jugular venous cannula placement or VVB was noted. In conclusion, percutaneous placement of a large bore venous return cannula for VVB during adult OLT can be performed with acceptable risk using a flexible 18-Fr cannula via the right internal jugular vein (IJV) by experienced attending transplant anesthesiologists.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology, University of Pittsburgh Medical Center Presbyterian/Montefiore Hospital, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
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DiCarlo JV, Auerbach SR, Alexander SR. Clinical review: alternative vascular access techniques for continuous hemofiltration. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10:230. [PMID: 16989669 PMCID: PMC1751070 DOI: 10.1186/cc5035] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Obtaining or maintaining vascular access for continuous hemofiltration can sometimes be problematic, especially in the child or adult in multiple organ failure with edema and/or coagulopathy. Problems commonly encountered include obstruction of the femoral vein by the catheter, insertion difficulties, safety concerns when cannulating the subclavian vein in coagulopathy, and catheter and circuit occlusion due to disseminated intravascular coagulation. For access in infants we describe a technique utilizing two single-lumen thin-walled vascular sheaths. For infants and small children initial access to the vein may be difficult due to edema or poor perfusion. For this situation we describe the 'mini-introducer' technique of securing the vein and facilitating subsequent insertion of a relatively large guide wire. At any age an alternative route to the subclavian vein, from above the clavicle, is potentially 'compressible' in the event of hemorrhage during the procedure. We remind the reader of the utility of ultrasound guidance for cannulation of the internal jugular and subclavian veins. And lastly we review the options for venous return via the umbilical vein in infants, and via the antecubital vein in larger children and adults.
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Affiliation(s)
- Joseph V DiCarlo
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Welch Road, Palo Alto, California 94304, USA
| | - Scott R Auerbach
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Welch Road, Palo Alto, California 94305, USA
| | - Steven R Alexander
- Division of Pediatric Nephrology, Stanford University School of Medicine, SUMC G306A, Stanford, California 94305, USA
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Barnett R. Pro: Veno-veno Bypass Should Routinely Be Used During Liver Transplantation. J Cardiothorac Vasc Anesth 2006; 20:742-3. [DOI: 10.1053/j.jvca.2006.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Indexed: 11/11/2022]
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15
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Azoulay D, Andreani P, Maggi U, Salloum C, Perdigao F, Sebagh M, Lemoine A, Adam R, Castaing D. Combined liver resection and reconstruction of the supra-renal vena cava: the Paul Brousse experience. Ann Surg 2006; 244:80-8. [PMID: 16794392 PMCID: PMC1570596 DOI: 10.1097/01.sla.0000218092.83675.bc] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Liver tumors with inferior vena cava (IVC) involvement may require combined resection of the liver and IVC. This approach, with its high surgical risks and poor long-term prognosis, was precluded until the development of neoadjuvant chemotherapy, portal vein embolization, reinforced vascular prostheses, and technical advances in liver transplantation. METHODS We reviewed 22 cases of hepatectomy with retrohepatic IVC resection and reconstruction. The patients had a median age of 51.5 years (range, 32.8-75.3 years). Indications for resection were: liver metastases (n = 9), cholangiocarcinoma (n = 8), hepatocellular carcinoma (n = 2), other cancers (n = 3). The liver resections carried out included 18 first, 3 second, and one third hepatectomy. Segment 1 (caudate lobe) was included in the specimen in 19 cases (86%). Resection concerned 1 to 6 liver segments (median = 5.0). Vascular control was achieved by vascular exclusion of the liver preserving the caval flow (n = 1), standard vascular exclusion of the liver (n = 12), in situ cold perfusion of the liver (n = 9). Ex situ surgery was not necessary in any case. Venovenous bypass was used in 12 cases. The IVC was reconstructed with a ringed Gore-Tex tube graft (n = 10), primarily (n = 8), or by caval plasty (n = 4). A main hepatic vein was reimplanted in 6 cases: into the native IVC (n = 4) or into a Gore-Tex tube graft (n = 2). RESULTS One patient died (4.5%) due to catheter infection, 7 days after in situ cold perfusion with replacement of the vena cava. Eight patients (36%) had no complications and 14 patients (64%) had 23 complications. In all but 1 case, the complications were transient and successfully controlled. The patients stayed in intensive care for 3.3 +/- 2.0 days and in the hospital for 17.7 +/- 7.8 days. All vascular reconstructions were patent at last follow-up. With median follow-up of 19 months, 10 patients died of tumor recurrence and eleven were alive with (n = 5) or without (n = 6) disease. Actuarial 1-, 3-, and 5-year survival rates were 81.8%, 38.3%, and 38.3%, respectively. CONCLUSIONS IVC resection and reconstruction combined with liver resection can be safely performed in selected patients. The lack of alternative treatments and the spontaneous poor prognosis justify this approach, provided that surgery is carried out at a center specialized in both liver surgery and liver transplantation. The development of adjuvant chemotherapy regimens is required to improve the long-term results of this salvage surgery.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France.
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Reddy K, Mallett S, Peachey T. Venovenous bypass in orthotopic liver transplantation: time for a rethink? Liver Transpl 2005; 11:741-749. [PMID: 15973707 DOI: 10.1002/lt.20482] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Kalpana Reddy
- Department of Anaesthesia, Royal Free Hospital, London, United Kingdom
| | - Susan Mallett
- Department of Anaesthesia, Royal Free Hospital, London, United Kingdom
| | - Tim Peachey
- Department of Anaesthesia, Royal Free Hospital, London, United Kingdom
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17
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Azoulay D, Eshkenazy R, Andreani P, Castaing D, Adam R, Ichai P, Naili S, Vinet E, Saliba F, Lemoine A, Gillon MC, Bismuth H. In situ hypothermic perfusion of the liver versus standard total vascular exclusion for complex liver resection. Ann Surg 2005; 241:277-85. [PMID: 15650638 PMCID: PMC1356913 DOI: 10.1097/01.sla.0000152017.62778.2f] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
SUMMARY BACKGROUND DATA We compare the results of liver resection performed under in situ hypothermic perfusion versus standard total vascular exclusion (TVE) of the liver <60 minutes and > or =60 minutes in terms of liver tolerance, liver and renal functions, postoperative morbidity, and mortality. The safe duration of TVE is still debated. Promising results have been reported following TVE associated with hypothermic perfusion of the liver with durations of up to several hours. The 2 techniques have not been compared so far. METHODS The study population includes 69 consecutive liver resections under TVE <60 minutes (group TVE<60', 33 patients), > or =60 minutes (group TVE> or =60', 16 patients), and in situ hypothermic perfusion (group TVEHYOPOTH, 20 patients). Liver tolerance (peaks of transaminases), liver and kidney function (peak of bilirubin, minimum prothrombin time, and peak of creatinine), morbidity, and in-hospital mortality were compared within the 3 groups. RESULTS The postoperative peaks of aspartate aminotransferase (IU/L) and alanine aminotransferase (IU/L) were significantly lower (P[r] < 0.05) in group TVE HYPOTH (450 +/- 298 IU/L and 390 +/- 391 IU/L) compared with the groups TVE<60' (1000 +/- 808; 853 +/- 743) and TVE> or =60' (1519 +/- 962; 1033 +/- 861). In the group TVEHYPOTH, the peaks of bilirubin (micromol/L) (84 +/- 31), creatinine (micromol/L) (75 +/- 22), and the number of complications per patient (1.2 +/- 0.9) were comparable to those of the group TVE<60' (80 +/- 111; 109 +/- 77; and 0.8 +/- 1.1 respectively) and significantly lower to those of the group TVE> or =60' (196 +/- 173; 176 +/- 176, and 2.6 +/- 1.8). In-hospital mortality rates were 1 in 33, 2 in 16, and 0 in 20 for the groups TVE<60', TVE> or =60', and TVEHYOPOTH, respectively, and were comparable. On multivariate analysis, the size of the tumor, portal vein embolization, and a planned vascular reconstruction were significantly predictive of TVE > or =60 minutes. CONCLUSIONS Compared with standard TVE of any duration, hypothermic perfusion of the liver is associated with a better tolerance to ischemia. In addition, compared with TVE > or =60 minutes, it is associated with better postoperative liver and renal functions and a lower morbidity. Predictive factors for TVE > or =60 minutes may help to indicate hypothermic perfusion of the liver.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Département de Chirurgie Hépato-Biliaire, IFR 89.9, Hôpital Paul Brousse, Villejuif, France.
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Budd JM, Isaac JL, Bennett J, Freeman JW. Morbidity and mortality associated with large-bore percutaneous venovenous bypass cannulation for 312 orthotopic liver transplantations. Liver Transpl 2001; 7:359-62. [PMID: 11303297 DOI: 10.1053/jlts.2001.22708] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study is to establish the incidence of serious morbidity and mortality associated with the placement of large-bore (18 to 20 F) percutaneous bypass cannulae for venovenous bypass (VVBP) during orthotopic liver transplantation (OLT). This technique has been reported to be rapid, simple, and safe. We reviewed the case notes of 312 patients who underwent OLT in our center using this technique. We describe 4 cases of serious morbidity (incidence, 1.28%) and 1 death (incidence, 0.32%) related directly to percutaneous placement of the bypass cannula. We conclude that percutaneous cannula placement for VVBP during OLT has the potential for life-threatening complications, and this must be considered when electing to use this technique. When percutaneous cannulae are to be used, we recommend the use of the right internal jugular vein for return cannulation and the use of ultrasound guidance, particularly in those patients in whom cannulation is predictably difficult.
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Affiliation(s)
- J M Budd
- Featherstone Department of Anaesthetics and Intensive Care, University Hospital Birmingham NHS Trust, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
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Neelakanta G, Csete M, Busuttil RW. Arteriovenous obstruction of arm due to venovenous bypass during liver transplantation. J Clin Anesth 1997; 9:507-9. [PMID: 9278842 DOI: 10.1016/s0952-8180(97)00110-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Two cases of arteriovenous obstruction of the right arm due to venovenous bypass during orthotopic liver transplantation are reported. Possible explanation and risk factors for the development of this complication are discussed.
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Affiliation(s)
- G Neelakanta
- Department of Anesthesiology and Surgery, UCLA-Dumont Liver Transplantation Center, UCLA School of Medicine 90095-1778, USA
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Scholz T, Aasen AO, Mathisen Ø, Bergan A, Soreide Ø, Osnes S, Innes R, Pedersen T. Percutaneous technique for venovenous bypass including a heat exchanger is safe and reliable in liver transplantation. Transpl Int 1997. [DOI: 10.1111/j.1432-2277.1997.tb00682.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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