An Orthotopic Liver Transplantation Patient Survived Without Hepatic Artery Flow Due to Thrombosis: A Case Report

The Use of Intraoperative Transit Time Flow Meter for the Early Detection and Prevention of Vascular Complications Following Adult Deceased Donor Liver Transplantation

PURPOSE

This study aims to determine whether intraoperative analysis of arterial and portal venous flow using transit time flow measurement (TTFM) data is associated with a reduced incidence of vascular complications after orthotopic liver transplantation.

METHODS

This is a retrospective chart review of all adult orthotopic liver transplant recipients at Saint Louis University Hospital from 2015-2020 (n = 188). We reviewed intraoperative flow probe use, as well as documentation of abnormal flow patterns detected during surgery. Normal graft flow measurements were defined as hepatic artery flow >100 ml/min and portal vein flow >0.5 ml/min/gram-liver. Postoperative imaging and ultrasonographic data were then reviewed for reports of vascular complications requiring intervention between the time of transplant and December 31, 2020. The incidence of VCs was compared between those who received intraoperative TTFM and those who did not. We then compared the demographic composition of these 2 groups to ensure similarity and screen for potential confounding factors.

RESULTS

188 liver transplant operative reports met the criteria for inclusion and were reviewed. TTFM use was documented in 78 (41.5%) cases and abnormal flow was detected in 8 (10.3%) of these cases, prompting intraoperative correction. Subsequently, no patients who received intraoperative TTFM developed vascular complications during the postoperative course. Conversely, of the 110 (58.5%) cases with no reported intraoperative flow data, 6 (5.5%, P = .042) patients later developed vascular complications. Reported vascular complications included hepatic artery stenosis, hepatic artery thrombosis, portal vein thrombosis, hepatic vein thrombosis, and IVC thrombosis. There was no significant difference in patient population between patients who received intraoperative TTFM and those who did not, apart from the type of liver implantation. There was a significantly higher prevalence of bicaval liver implantations in the group of patients who did not receive TTFM than those who did (P = .002).

CONCLUSIONS

Transit time flow measurement may be a useful tool for the detection of vascular flow abnormalities intraoperatively, allowing for early correction and prevention of vascular complications during the postoperative course. This could potentially result in enhanced graft survival and reduced recipient mortality following orthotopic liver transplantation.

Enterococcus avium Infection After Liver Transplantation in Vietnam: A Case Report

BACKGROUND

The infectious complications are the most common and can be life-threatening to liver transplant recipients, in particular, within the first month after transplantation. Early diagnosis of these severe complications and accurate detection of causative etiologies are crucial for the choice of therapeutic strategies and management of liver transplants.

CASE REPORT

We present a case report of a patient with a history of primary sclerosing cholangitis who underwent a liver transplantation (LT) from a living donor. The postoperative care was complicated with the hepatic artery thrombosis on day 16 and then the presence of sepsis on day 22 and intra-abdominal abscess on day 30, caused by Enterococcus avium (E. avium). The patient was treated with stent placement for hepatic artery thrombosis, percutaneous drainage of the abscess, and used an intensive intravenous antibiotic regimen with a combination of fosfomycin and vancomycin for a duration of 14 days. After the interventional procedure, the clinical examination and laboratory findings became normal and the patient left the hospital on day 46 in good general condition.

CONCLUSION

We diagnosed early and well-recognized complications during the perioperative care to make a prompt therapeutic approach with conservative treatment to rescue the patient without requiring urgent surgery and retransplantation.

Comparison of 2 Different Types of Arterial and Biliary Anastomoses While Preserving the Gastroduodenal Artery: A Retrospective Study

OBJECTIVE

Here we investigated 2 different arterial reconstruction procedures with preservation of the gastroduodenal artery (GDA) in orthotopic liver transplantation (OLT).

METHODS

A retrospective cohort study was conducted. The clinicopathological data of 40 pairs of donors and recipients who underwent OLT from May 2018 to August 2023 were analyzed. The GDA of all recipients was preserved during the hepatic arteries reconstruction, which were divided into 2 groups according to different anastomosis locations, namely the end-to-side group (E-S group, n = 17, Branch-patch between the common hepatic and the gastroduodenal artery) and end-to-end group (E-E group, n = 23, between common hepatic and proper hepatic).

RESULTS

Demographics did not differ between both groups (P > .05). The warm ischemia time (WIT) was numerically longer in the E-S group (403.3 ± 103.3 vs 195.2 ± 35.8 s; P < .001), but the cold ischemia time (CIT) was numerically shorter in the E-S group (279.2 ± 74.7 vs 325.2 ± 15.1 min; P = .023). The time of artery reconstruction and duration of surgery was numerically shorter in the E-S group (21.0 ± 3.6 vs 51.0 ± 9.1 min, P < .001; 326.0 ± 103.4 vs 422.7 ± 24.6 min, P = .001). The E-S group had a lower resistance index (RI) (0.5 ± 0.3 vs 0.6 ± 0.1; P = .049).

CONCLUSION

Both groups showed no differences in artery and biliary complications. GDA preservation meets the anatomical and physiological requirements. E-S is superior to E-E by the time of hepatic artery reconstruction and RI.

Use of Intraoperative Doppler Ultrasonography in Predicting Life-Threatening Vascular Complications After Adult Deceased Donor Liver Transplantation

Aim This study aims to determine if routine use of intraoperative Doppler ultrasonography is preventative of life-threatening vascular complications (VCs) after orthotopic liver transplantation. Methods This single-center, retrospective study reviewed all adult orthotopic liver transplants at Saint Louis University Hospital from 2015 to 2020 (N = 188). The sample population consists of men and women in the age range of 18 to 75. Operative reports were reviewed for the use of intraoperative ultrasound (IOUS) and the associated resistive indices, peak systolic velocities, and qualitative assessments of flow. Postoperative VCs were identified as complications requiring intervention between the time of transplant and December 31, 2020. Life-threatening VCs were defined by the presence of vascular thrombosis. The primary outcome was the incidence of postoperative life-threatening VCs between those in which intraoperative DUS was performed and those in which it was not. Results IOUS was documented in 35 (18.6%) cases. All cases using IOUS demonstrated good flow and no abnormalities, as reported by the operating surgeon. There was no difference in patient population between those who received IOUS and those who did not. Postoperative life-threatening VCs were identified in five cases. Of the cases in which no IOUS was performed, five (3.3%) had life-threatening VCs. Of the patients with documented IOUS, 0 (0%) had life-threatening VCs. Conclusions The IOUS group showed a lower incidence of life-threatening VCs (0%) compared to the no IOUS group, which had a 3.3% life-threatening complication rate. However, this was not statistically significant due to the small number of VCs, as VCs following liver transplants are inherently rare. With these results in combination with current literature, there is support for the use of IOUS in preventing and predicting VCs.