Portal revascularization in the setting of cavernous transformation through a paracholedocal vein: a case report

A Novel Preoperative Classification System for Selecting Suitable Surgeries in Liver Transplant Patients with Portal Vein Cavernous Transformation

BACKGROUND

To evaluate the new preoperative Changgung classification (CC) system of portal vein thrombosis (PVT) in choosing suitable operative procedures to reconstruct portal veins during liver transplantation (LT) in patients with portal vein cavernous transformation (PVCT).

METHODS

This retrospective observational study analyzed data from allograft LTs performed for various liver diseases.

RESULTS

The study included 22 males and 4 females with LT indications comprising cirrhosis (n = 9), hepatocellular carcinoma (n = 12), PVCT (n = 2), liver failure from fulminant hepatitis B (n = 1), dysfunction of transplanted liver (n = 1), and chronic rejection of transplanted liver (n = 1). Patients were classified according to Yerdel (21 Yerdel II and 5 Yerdel III) and CC (C1-C5). In total 16 simple operations were performed on C1-C3 cases and 9 complex operations on C4-C5 cases, with one additional simple operation. The distribution according to the Yerdel classification was 16 simple and 5 complex operations in Yerdel II cases and 1 simple and 4 complex operations in Yerdel III cases. The median follow-up time was 27.5 months with overall one-year and three-year OS rates of 88.1% and 83.9% for the cohort. Specifically, the one-year OS rates for patients classified as C1-3 vs. C4-5 were 93.3% and 80.0%, while the three-year OS rates were 86.7% and 80.0%, respectively (p = 0.526).

CONCLUSION

The CC proposed in this study shows comparable potential to the Yerdel classification in preoperatively identifying the need for complex surgical techniques in LT patients with PVCT and may also have predictive power for the survival benefits following LT.

Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis

BACKGROUND & AIMS

Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT.

METHODS

An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021.

RESULTS

A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001).

CONCLUSIONS

Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed.

IMPACT AND IMPLICATIONS

Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.

Using Pericholedochal Varix Inflow for Complete Portal Vein Thrombosis in Living Donor Liver Transplantation: A Case Report

One of the crucial steps of liver transplantation is to provide the portal inflow. Portal vein thrombosis is the most challenging factor to achieve. Using a pericholedochal varix for portal inflow in a patient with complete portal vein thrombosis in living donor liver transplantation (LDLT) is a rare technique. We present our experience of a LDLT with PVT.

Optimal Treatment for Patients With Cavernous Transformation of the Portal Vein

Cavernous transformation of the portal vein (CTPV) is a sequela of extrahepatic and/or intrahepatic portal vein obstruction caused by a combination of local and risk factors. It was ever taken as a relatively rare disease due to its scant literature, which was mainly based on clinical series and case reports. CTPV often manifests as gastroesophageal variceal bleeding, splenomegaly, and portal biliopathy after the long-term insidious presentation. It is unable for CTPV to be recanalized with anticoagulation because it is a complete obstruction of the mesentericoportal axis. Endoscopic therapy is mainly used for temporary hemostasis in acute variceal bleeding. Meso-Rex shunting characterized by portal-flow-preserving shunts has been widely performed in children with CTPV. The multitude of complications associated with CTPV in adults can be effectively addressed by various interventional vascular therapies. With the ubiquity of radiological examinations, optimal treatment for patients with CTPV becomes important. Multivisceral transplantation, such as liver-small intestinal transplantation, may be lifesaving and should be considered for patients with diffuse mesenteric venous thrombosis.

Revascularization for cavernous transformation radical lymphadenectomy in the treatment of gastric cancer: A case report

INTRODUCTION

There are few reported cases of cavernous transformation of the portal vein (CTPV). CTPV is usually found by accident because most patients are asymptomatic at presentation. This paper reports a case of early gastric cancer with CTPV that required gastrectomy and revascularization.

PRESENTATION OF CASE

A 71-year-old man diagnosed with early gastric cancer, which was classified as clinical Stage IA (T1b, N0, M0) according to the TNM classification criteria for gastric cancer, was admitted to our hospital. Preoperative computed tomography (CT) revealed portal vein stenosis, CTPV, and esophageal varix. CT angiography showed that portal flow was maintained by the left gastric vein-right gastric vein (LGV-RGV) shunt. We had to perform lymphadenectomy while maintaining the hepatic blood flow. We performed distal gastrectomy with lymph node dissection including the vessel of the lesser curvature without massive bleeding. Postoperative course was uneventful, and CT examination performed in the 7th postoperative day revealed good blood flow from the reconstructed collateral vessels. The patient had no recurrence of gastric cancer during the postoperative period of 1 year.

CONCLUSION

Diseases that cause intra-abdominal inflammation, such as pancreatitis and choledocholithiasis, might cause CTPV. Thus, patients with this medical history should be carefully assessed for CTPV to avoid intraoperative complications, such as massive bleeding or ischemia. When we preform operation a case with CTPV, we must pay meticulous attention. In our case, we encountered some difficulties in the surgical procedure, especially with respect to the dissection of the regional lymph nodes for gastric cancer.

The collateral caval shunt as an alternative to classical shunt procedures in patients with recurrent duodenal varices and extrahepatic portal vein thrombosis

Upper gastrointestinal bleeding episodes from variceal structures are severe complications in patients with portal hypertension. Endoscopic sclerotherapy and variceal ligation are the treatment options preferred for upper variceal bleeding owing to extrahepatic portal hypertension due to portal vein thrombosis (PVT). Recurrent duodenal variceal bleeding in non-cirrhotic patients with diffuse porto-splenic vein thrombosis and subsequent portal cavernous transformation represent a clinical challenge if classic shunt surgery is not possible or suitable.

In this study, we represent a case of recurrent bleeding of duodenal varices in a non-cirrhotic patient with cavernous transformation of the portal vein that was successfully treated with a collateral caval shunt operation.

The paracholedochal vein: a feasible option as portal inflow in living donor liver transplantation

Extensive thrombosis of the portal and splenomesenteric veins combined with cavernous transformation of the portal vein (CTPV) has been considered to be a contraindication for living donor liver transplantation (LDLT) due to technical difficulties and perioperative risks. In recent years, several surgical innovations including cavoportal hemitransposition, renoportal anastomosis, and portal arterialization have been introduced to overcome diffuse portal vein thrombosis (PVT) and CTPV, but their outcomes were unsatisfactory with significant morbidity and mortality. Herein, we report two successful cases of adult LDLT in diffuse PVT with CTPV managed using the paracholedochal vein as portal inflow to the graft.

Trombose de veia porta no transplante hepático

INTRODUÇÃO: A trombose de veia porta foi considerada contraindicação ao transplante de fígado no passado em razão da elevada morbi-mortalidade. Diversos avanços permitiram melhora dos resultados. OBJETIVO: Revisão dos avanços e das estratégias cirúrgicas utilizadas para realização do transplante de fígado na vigência de trombose de veia porta. MÉTODO: Revisão da literatura nas bases de dados Medline, Scielo, Lilacs cruzando os descritores: portal vein thrombosis, liver transplantation, vascular complications, jump graft, graft failure, multivisceral transplant. Foram estudados a epidemiologia, fatores de risco, classificação, diagnóstico, estratégias cirúrgicas e resultados. CONCLUSÃO: A trombose de veia porta deixou de ser contraindicação para o transplante hepático. O cirurgião dispõe atualmente de uma série de estratégias para realização do transplante, variando conforme o grau da trombose. Apesar de implicar em maior morbidade e taxas de re-trombose, os resultados do transplante na presença de trombose portal são semelhantes aos observados nas séries habituais.