Side-to-side cavocavostomy in adult piggyback liver transplantation

Utility of Falciform Ligament in Abdominal Surgery: A Systematic Review

OBJECTIVE

The aim of the present systematic review was to assess current trends in use of falciform ligament in abdominal surgery.

BACKGROUND

The falciform ligament has been proposed in surgical literature as a suitable pedicle or flap with acceptable surgical outcomes; however, it is underutilized in abdominal surgery.

METHODS

We performed a literature search and meta-analysis. All English studies describing use of a falciform ligament were eligible for inclusion.

RESULTS

Of the 547 articles mentioning use of falciform ligament, 32 full text articles were included in this review. The majority were case reports (n = 14). The mremaining papers included retrospective analysis (n = 10), randomized control trials (n = 2), reviews (n = 3), and technique descriptions (n = 6).

CONCLUSION

The falciform ligament appears to be a safe and easily accessible natural tissue with a variety of surgical applications. It is most useful as a pedicle flap and could have benefit in foregut surgery including hepatic, pancreatic, biliary, gastric, and esophageal operations.

Hepatic Venous Outflow Obstruction in Adult Deceased Donor Liver Transplantation: Classic Piggyback Implantation Versus a Modified Technique that Widens the Ostium of the Recipient's Left and Middle Hepatic Veins

BACKGROUND

The classic piggyback technique uses the union of the 3 hepatic veins to perform the cavo-caval anastomosis. However, due to the lateral localization of the right hepatic vein, the partial clamping of the vena cava in this technique significantly reduces the venous return to the right atrium. To avoid this, we adopted in 2015 a modified piggyback technique, in which we use the common trunk of the middle and left hepatic veins and also perform a lateral incision toward the right in the anterior wall of the vena cava in order to widen the final ostium of the cavo-caval anastomosis. The aim of the study was to analyze the incidence of hepatic venous outflow obstruction between those 2 techniques.

METHODS

Retrospective study of liver transplant recipients undergoing venography for suspected hepatic venous outflow obstruction from January 2009 to June 2021. Patients undergoing transplantation with living donors or split grafts and pediatric cases were excluded from the study.

RESULTS

From January 2009 to December 2014 and from January 2015 to June 2021, 587 (group 1) and 730 (group 2) deceased-donor liver transplants were performed with the classic and the modified piggyback techniques, respectively. The incidence of cases with suspected hepatic venous outflow obstruction in groups 1 and 2 were 1.87% (n = 11) and 0.95% (n = 7), respectively (P = 0,15). The number of confirmed patients with outflow blockage that required endovascular treatment during venography in groups 1 and 2 were 4 (0.68%) and 5 (0.68%), respectively (P = 0,31).

CONCLUSIONS

This modified piggyback technique did not increase the incidence of hepatic venous outflow obstruction at our service.

Is Surgery Necessary? Endoscopic Management of Post-transplant Biliary Complications in the Modern Era

BACKGROUND

Biliary complications are common following liver transplantation (LT) and traditionally managed with Roux-en-Y hepaticojejunostomy. However, endoscopic management has largely supplanted surgical revision in the modern era. Herein, we evaluate our experience with the management of biliary complications following LT.

METHODS

All LTs from January 2013 to June 2018 at a single institution were reviewed. Patients with biliary bypass prior to, or at LT, were excluded. Patients were grouped by biliary complication of an isolated stricture, isolated leak, or concomitant stricture and leak (stricture/leak).

RESULTS

A total of 462 grafts were transplanted into 449 patients. Ninety-five (21%) patients had post-transplant biliary complications, including 56 (59%) strictures, 28 (29%) leaks, and 11 (12%) stricture/leaks. Consequently, the overall stricture, leak, and stricture/leak rates were 12%, 6%, and 2%, respectively. Endoscopic management was pursued for all stricture and stricture/leak patients, as well as 75% of leak patients, reserving early surgery only for those patients with an uncontrolled leak and evidence of biliary peritonitis. Endoscopic management was successful in the majority of patients (stricture 94%, leak 90%, stricture/leak 90%). Only six patients (5.6%) received additional interventions-two required percutaneous transhepatic cholangiography catheters, three underwent surgical revision, and one was re-transplanted.

CONCLUSIONS

Endoscopic management of post-transplant biliary complications resulted in long-term resolution without increased morbidity, mortality, or graft failure. Successful endoscopic treatment requires collaboration with a skilled endoscopist. Moreover, multidisciplinary transplant teams must develop treatment protocols based on the local availability and expertise at their center.

Normal and transitory ultrasonography findings in the immediate postoperative period after liver transplantation

OBJECTIVE

Liver transplantation is one of the treatments for patients with advanced stage chronic liver disease and for selected patients with hepatic tumors. Ultrasonography is the first-choice imaging technique to evaluate liver transplants. This article reviews the surgical technique, anatomy, and normal findings on ultrasonography in the immediate postoperative period in patients who have undergone liver transplantation, which will be used as a reference in follow-up studies.

CONCLUSION

Early vascular (arterial and portal) complications can represent a threat for the graft or the patient. During the period after liver transplantation, the patient is recovering from surgery and the transplanted organ is adapting to its new environment. In this period, ultrasonography can show alterations in the parenchyma or Doppler findings that would be considered abnormal in other situations; these findings are usually transitory. Knowing how to interpret them is key to detecting or ruling out complications.

Imaging follow-up after liver transplantation

Liver transplantation (LT) represents the best treatment for end-stage chronic liver disease, acute liver failure and early stages of hepatocellular carcinoma. Radiologists should be aware of surgical techniques to distinguish a normal appearance from pathological findings. Imaging modalities, such as ultrasound, CT and MR, provide for rapid and reliable detection of vascular and biliary complications after LT. The role of imaging in the evaluation of rejection and primary graft dysfunction is less defined. This article illustrates the main surgical anastomoses during LT, the normal appearance and complications of the liver parenchyma and vascular and biliary structures.

Caval reconstruction techniques in orthotopic liver transplantation

There are several caval reconstruction techniques currently in use for orthotopic liver transplantation. These include caval replacement or the conventional technique, performed with or without venovenous bypass, piggyback technique with anastomosis with two or three hepatic veins with or without cavotomy and modifications of the piggyback technique including end-to-side and side-to-side cavocaval anastomosis. There are few randomized controlled trials comparing the use of these techniques and our knowledge of their comparability is based on a few multi- and many single-center retrospective and prospective reviews. Although there are advantages and disadvantages for each technique, it is advisable that the surgeon perform the technique with which they have the most the experience and at which they are the most skilled as excellent outcomes can be obtained with any of the caval reconstruction options discussed.

Liver transplantation with piggyback anastomosis using a linear stapler: a case report

The so-called piggyback technique of liver transplantation (PB-LT) preserves the recipient's caval vein, shortening the warm ischemic time. It can be reduced even further by using a linear stapler for the cavocaval anastomosis. Herein, we have presented a case of a patient undergoing a side-to-side, whole-organ PB-LT for cryptogenic cirrhosis. Upper and lower orifices of the donor caval vein were closed at the back table using a running 5-0 polypropylene suture. Three stay sutures were then placed on caudal parts of both the recipient and donor caval with a 5-mm venotomies. The endoscopic linear stapler was placed upward through the orifices and fired. A second stapler was placed more cranially and fired resulting in a 8-9 cm long cavocavostomy. Some loose clips were flushed away from the caval lumen. The caval anastomosis was performed within 4 minutes; the time needed to close the caval vein stapler insertion orifices (4-0 polypropylene running suture) before reperfusion was 1 minute. All other anastomoses were performed as typically sutured. The presented technique enables one to reduce the warm ischemic time, which can be of particular importance with marginal grafts.