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Lim C, Saliba F, Salloum C, Azoulay D. Revisiting the place of surgical portal decompression for adults with noncirrhotic portal hypertension due to chronic extrahepatic portal vein obstruction: a scoping review. HPB (Oxford) 2025; 27:434-444. [PMID: 39863431 DOI: 10.1016/j.hpb.2025.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 11/22/2024] [Accepted: 01/07/2025] [Indexed: 01/27/2025]
Abstract
BACKGROUND Liver cirrhosis accounts for more than 90 % of portal hypertension cases, and the other cases are due to noncirrhotic portal hypertension (NCPH). Variceal bleeding is the most life-threatening complication of portal hypertension and its primary treatment is medical according to the Baveno VII guidelines. This review discusses the evidence on surgical portal decompression for adult patients with NCPH secondary to chronic extrahepatic portal vein obstruction (EHPVO). METHODS This is a scoping review of the evidence for the feasibility and effectiveness of surgical portal decompression in adults with NCPH secondary to EHPVO. RESULTS This scoping review yielded 17 studies, including a total of 110 patients. Patient age(s) ranged from 19 to 68 years, with the majority undergoing nonphysiological (i.e., portosystemic shunts) shunts (N = 84, 76.4 %), mostly for variceal bleeding refractory to medical and endoscopic treatments. Physiological shunts (i.e., Rex shunts) had a potential advantage over nonphysiological shunts in postoperative rebleeding (5 % vs. 10 %) and hepatic encephalopathy rates (0 % vs. 13 %). Conversely, nonphysiological shunts had a potential advantage over physiological shunts in postoperative shunt thrombosis (8 % vs. 22 %). DISCUSSION This scoping review reported that surgical portal decompression is feasible in adults with NCPH due to EHPVO with favorable outcomes and long-term patency.
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Affiliation(s)
- Chetana Lim
- Department of Digestive, Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Research Unit, Université de Picardie-Jules Verne, UR UPJV 7518 SSPC, Amiens, France
| | - Faouzi Saliba
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, Paris-Saclay University, INSERM Unit 1193, 94800 Villejuif, France
| | - Chady Salloum
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, Paris-Saclay University, INSERM Unit 1193, 94800 Villejuif, France
| | - Daniel Azoulay
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, Paris-Saclay University, INSERM Unit 1193, 94800 Villejuif, France.
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2
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Rajendran V, Joy D, Sudheer Mohammed, Chandran B, Jacob M. Management of Preoperative Recipient Portal Vein Thrombosis in Living-donor Liver Transplantation. J Clin Exp Hepatol 2025; 15:102445. [PMID: 39802411 PMCID: PMC11714416 DOI: 10.1016/j.jceh.2024.102445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 10/17/2024] [Indexed: 01/16/2025] Open
Abstract
Portal vein thrombosis (PVT) occurs as a part of the natural history of cirrhosis in up to 15% of patients with cirrhosis. In the initial days, PVT was considered a contraindication to liver transplantation, but now with advanced techniques and perioperative management, patients with complex PVT also undergo living-donor liver transplantation (LDLT) with a similar outcome. This review provides a comprehensive overview of methods to proceed with liver transplantation when the recipient has PVT. Preoperatively, anticoagulation remains the mainstay of treatment, with transjugular intrahepatic portosystemic shunt (TIPS) playing an adjunct role in preparing patients for liver transplantation. In all patients, thrombectomy with re-establishment of physiological portal flow is the initial step. In patients where flow cannot be established, other physiological or nonphysiological means are employed, especially in complex PVT. Patients with grade III/IV PVT have worse outcomes (graft failure, mortality, recurrence) than those with lower-grade PVT. Physiological reconstruction is the method of choice, whereas non-physiological means are used as a bailout procedure.
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Affiliation(s)
- Vivek Rajendran
- Aster Integrated Liver Care, Aster Medcity, Cheranallur, Kochi 682027, India
| | - Danny Joy
- Aster Integrated Liver Care, Aster Medcity, Cheranallur, Kochi 682027, India
| | - Sudheer Mohammed
- Aster Integrated Liver Care, Aster Medcity, Cheranallur, Kochi 682027, India
| | - Biju Chandran
- Aster Integrated Liver Care, Aster Medcity, Cheranallur, Kochi 682027, India
| | - Mathew Jacob
- Aster Integrated Liver Care, Aster Medcity, Cheranallur, Kochi 682027, India
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3
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Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. [Not Available]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
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Zhang IW, Lurje I, Lurje G, Knosalla C, Schoenrath F, Tacke F, Engelmann C. Combined Organ Transplantation in Patients with Advanced Liver Disease. Semin Liver Dis 2024; 44:369-382. [PMID: 39053507 PMCID: PMC11449526 DOI: 10.1055/s-0044-1788674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Transplantation of the liver in combination with other organs is an increasingly performed procedure. Over the years, continuous improvement in survival could be realized through careful patient selection and refined organ preservation techniques, in spite of the challenges posed by aging recipients and donors, as well as the increased use of steatotic liver grafts. Herein, we revisit the epidemiology, allocation policies in different transplant zones, indications, and outcomes with regard to simultaneous organ transplants involving the liver, that is combined heart-liver, liver-lung, liver-kidney, and multivisceral transplantation. We address challenges surrounding combined organ transplantation such as equity, utility, and logistics of dual organ implantation, but also advantages that come along with combined transplantation, thereby focusing on molecular mechanisms underlying immunoprotection provided by the liver to the other allografts. In addition, the current standing and knowledge of machine perfusion in combined organ transplantation, mostly based on center experience, will be reviewed. Notwithstanding all the technical advances, shortage of organs, and the lack of universal eligibility criteria for certain multi-organ combinations are hurdles that need to be tackled in the future.
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Affiliation(s)
- Ingrid Wei Zhang
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin, Berlin, Germany
- European Foundation for the Study of Chronic Liver Failure (EF CLIF) and Grifols Chair, Barcelona, Spain
| | - Isabella Lurje
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Lurje
- Department of Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Cornelius Engelmann
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin, Berlin, Germany
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5
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Iyer KR. Indications for Intestinal Transplantation. Gastroenterol Clin North Am 2024; 53:233-244. [PMID: 38719375 DOI: 10.1016/j.gtc.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Outcomes for patients with chronic intestinal failure have improved with organization of experts into multidisciplinary teams delivering care in intestinal rehabilitation programs. There have been improvements in understanding of intestinal failure complications as well as development of newer therapies that have amplified the improvements in survival. In spite of this encouraging trend, patients who fail PN are often referred too late for intestinal transplantation. The author proposes a more rational framework that might allow earlier identification of intestinal failure patients at risk for PN-failure, who could appropriately be considered earlier for intestinal transplantation with improvements in overall outcomes.
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Affiliation(s)
- Kishore R Iyer
- Intestinal Rehabilitation & Transplant Program, Icahn School of Medicine at Mount Sinai and Mount Sinai Hospital, One Gustave Levy Place, Box 1104, New York 10029, USA.
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6
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Di Cocco P, Martinino A, Lian A, Johnson J, Spaggiari M, Tzvetanov I, Benedetti E. Indications for Multivisceral Transplantation: A Systematic Review. Gastroenterol Clin North Am 2024; 53:245-264. [PMID: 38719376 DOI: 10.1016/j.gtc.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Consensus remains elusive in the definition and indications of multivisceral transplantation (MVT) within the transplant community. MVT encompasses transplantation of all organs reliant on the celiac artery axis and the superior mesenteric artery in different combinations. Some institutions classify MVT as involving the grafting of the stomach or ascending colon in addition to the jejunoileal complex. MVT indications span a wide spectrum of conditions, including tumors, intestinal dysmotility disorders, and trauma. This systematic review aims to consolidate existing literature on MVT cases and their indications, providing an organizational framework to comprehend the current criteria for MVT.
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Affiliation(s)
- Pierpaolo Di Cocco
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Alessandro Martinino
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA.
| | - Amy Lian
- University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Jess Johnson
- University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Mario Spaggiari
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Ivo Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Enrico Benedetti
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
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7
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Di Benedetto F, Magistri P, Di Sandro S, Boetto R, Tandoi F, Camagni S, Lauterio A, Pagano D, Nicolini D, Violi P, Dondossola D, Guglielmo N, Cherchi V, Lai Q, Toti L, Bongini M, Frassoni S, Bagnardi V, Mazzaferro V, Tisone G, Rossi M, Baccarani U, Ettorre GM, Caccamo L, Carraro A, Vivarelli M, Gruttadauria S, De Carlis L, Colledan M, Romagnoli R, Cillo U. Portal vein thrombosis and liver transplantation: management, matching, and outcomes. A retrospective multicenter cohort study. Int J Surg 2024; 110:2874-2882. [PMID: 38445440 PMCID: PMC11093465 DOI: 10.1097/js9.0000000000001149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/26/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND AND AIMS Besides the increased risk of perioperative morbidity, graft failure, and mortality, the majority of PVT are diagnosed at liver transplantation (LT). Improving preoperative management and patient selection may lead to better short-term and long-term outcomes and reduce the risk of a futile LT. The authors aimed to identify predictors of adverse outcomes after LT in patients with nonmalignant portal vein thrombosis (PVT) and improve donor to recipient matching by analyzing the results of the Italian cohort of LT recipients. METHODS Adult patients who underwent LT in Italy between January 2000 and February 2020 diagnosed with PVT pre-LT or at time of LT were considered eligible for inclusion. Based on a survey encompassing all 26 surgeons participating in the study, a binary composite outcome was defined. Patients were classified as having the composite event if at least one of these conditions occurred: operative time more than 600 min, estimated blood loss greater than 5000 ml, more than 20 ICU days, 90 days mortality, 90 days retransplant. RESULTS Seven hundred fourteen patients were screened and 698 met the inclusion criteria. The analysis reports the results of 568 patients that fulfilled the criteria to enter the composite outcome analysis.Overall, 156 patients (27.5%) developed the composite outcome. PVT stage 3/4 at transplant and need for any surgical correction of PVT are independent predictors of the composite outcome occurrence. When stratified by PVT grade, overall survival at 1-year ranges from 89.0% with PVT grade 0/1 to 67.4% in patients with PVT grade 3/4 at LT ( P <0.001). Nevertheless, patients with severe PVT can improve their survival when identified risk factors are not present. CONCLUSIONS Potential LT candidates affected by PVT have a benefit from LT that should be adequately balanced on liver function and type of inflow reconstruction needed to mitigate the incidence of adverse events. Nonetheless, the absence of specific risk factors may improve the outcomes even in patients with PVT grades 3-4.
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Affiliation(s)
- Fabrizio Di Benedetto
- Hepato-pancreato-biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena
| | - Paolo Magistri
- Hepato-pancreato-biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena
| | - Stefano Di Sandro
- Hepato-pancreato-biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena
| | - Riccardo Boetto
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova
| | - Francesco Tandoi
- Liver Transplant Unit, General Surgery 2U, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin
| | - Stefania Camagni
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo
| | - Andrea Lauterio
- General Surgery and Abdominal Transplantation Unit, Niguarda-Cà Granda Hospital, Milan
- University of Milano-Bicocca
| | | | - Daniele Nicolini
- Hepatobiliary, Pancreatic and Transplantation Surgery, Dept. of Experimental and Clinical Medicine, Polytechnic University of Marche
| | - Paola Violi
- Department of General Surgery and Dentistry, Liver Transplant Unit, University Hospital of Verona, Verona
| | - Daniele Dondossola
- Fondazione IRCCS Ospedale Maggiore Policlinico, Università degli Studi, Milan
| | - Nicola Guglielmo
- Department of General Surgery and Transplantation, San Camillo-Forlanini General Hospital, Rome
| | - Vittorio Cherchi
- Liver-Kidney Transplant Unit, Department of Medicine, University of Udine, Udine
| | - Quirino Lai
- Department of General Surgery and Organ Transplantation, Sapienza University
| | - Luca Toti
- Department of Surgery Science, Transplant and HPB Unit, University of Rome Tor Vergata, Rome
| | - Marco Bongini
- Department of Oncology and Hemato-Oncology, University of MilanHepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan
| | - Vincenzo Mazzaferro
- Department of Oncology and Hemato-Oncology, University of MilanHepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano
| | - Giuseppe Tisone
- Department of Surgery Science, Transplant and HPB Unit, University of Rome Tor Vergata, Rome
| | - Massimo Rossi
- Department of General Surgery and Organ Transplantation, Sapienza University
| | - Umberto Baccarani
- Liver-Kidney Transplant Unit, Department of Medicine, University of Udine, Udine
| | - Giuseppe Maria Ettorre
- Department of General Surgery and Transplantation, San Camillo-Forlanini General Hospital, Rome
| | - Lucio Caccamo
- Fondazione IRCCS Ospedale Maggiore Policlinico, Università degli Studi, Milan
| | - Amedeo Carraro
- Department of General Surgery and Dentistry, Liver Transplant Unit, University Hospital of Verona, Verona
| | - Marco Vivarelli
- Hepatobiliary, Pancreatic and Transplantation Surgery, Dept. of Experimental and Clinical Medicine, Polytechnic University of Marche
| | | | - Luciano De Carlis
- General Surgery and Abdominal Transplantation Unit, Niguarda-Cà Granda Hospital, Milan
- University of Milano-Bicocca
| | - Michele Colledan
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo
- General Surgery and Abdominal Transplantation Unit, Niguarda-Cà Granda Hospital, Milan
- University of Milano-Bicocca
| | - Renato Romagnoli
- Liver Transplant Unit, General Surgery 2U, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin
| | - Umberto Cillo
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova
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8
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Raghu VK, Rumbo C, Horslen SP. From intestinal failure to transplantation: Review on the current need for transplant indications under multidisciplinary transplant programs worldwide. Pediatr Transplant 2024; 28:e14756. [PMID: 38623905 PMCID: PMC11115375 DOI: 10.1111/petr.14756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/24/2023] [Accepted: 04/01/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Intestinal failure, defined as the loss of gastrointestinal function to the point where nutrition cannot be maintained by enteral intake alone, presents numerous challenges in children, not least the timing of consideration of intestine transplantation. OBJECTIVES To describe the evolution of care of infants and children with intestinal failure including parenteral nutrition, intestine transplantation, and contemporary intestinal failure care. METHODS The review is based on the authors' experience supported by an in-depth review of the published literature. RESULTS The history of parenteral nutrition, including out-patient (home) administration, and intestine transplantation are reviewed along with the complications of intestinal failure that may become indications for consideration of intestine transplantation. Current management strategies for children with intestinal failure are discussed along with changes in need for intestine transplantation, recognizing the difficulty in generalizing recommendations due to the high level of heterogeneity of intestinal pathology and residual bowel anatomy and function. DISCUSSION Advances in the medical and surgical care of children with intestinal failure have resulted in improved transplant-free survival and a significant fall in demand for transplantation. Despite these improvements a number of children continue to fail rehabilitative care and require intestine transplantation as life-saving therapy or when the burden on ongoing parenteral nutrition becomes too great to bear.
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Affiliation(s)
- Vikram K. Raghu
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224
| | - Carolina Rumbo
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Simon P. Horslen
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224
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9
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Gondolesi GE. History of clinical intestinal transplantation. Hum Immunol 2024; 85:110788. [PMID: 38519405 DOI: 10.1016/j.humimm.2024.110788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 03/24/2024]
Abstract
The intestines have been considered the "forbidden organ" for years, and intestinal failure became the last organ failure recognized as such in the medical field. The impossibility of providing adequate nutritional support, turned these patients into recipients of just palliative comfort. In the 1960's, parenteral nutrition appeared as the most reasonable replacement therapy, but the initial success obtained with clinical kidney, heart, liver, lung and pancreas transplantation served as background to explore intestinal transplantation. The first clinical report of an isolated intestinal transplant was done by Richard Lillihei in 1967; in 1983, Thomas Starzl, performed the first multi visceral transplant, and in 1990, David Grant performed the first combined liver-intestinal transplant in an adult recipient in Canada. Since then, advances in immunosuppressive therapies and surgical innovations have allowed not only a continuous increase in indications, but also a worldwide application of all procedures, bringing clinical intestinal transplantation to reality. In this historical account, the most important contributions have been summarized, thus describing the steady progress, expansion and novelties developed over the last 56 years, since the first attempt. Clinical intestinal transplantation remains a complex and evolving field; ongoing research and technological advancements will continue shaping its future.
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Affiliation(s)
- Gabriel E Gondolesi
- Chief of General Surgery, Chief of Liver, Intestine and Pancreas Transplant, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina.
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10
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Abreu P, Manzi J, Vianna R. Innovative surgical techniques in the intestine and multivisceral transplant. Curr Opin Organ Transplant 2024; 29:88-96. [PMID: 37902277 DOI: 10.1097/mot.0000000000001098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
PURPOSE OF REVIEW This timely review delves into the evolution of multivisceral transplantation (MVT) over the past six decades underscoring how advancements in surgical techniques and immunosuppression have driven transformation, to provide insight into the historical development of MVT, shedding light on its journey from experimentation to a valuable clinical approach. RECENT FINDINGS The review presents contemporary enhancements in surgical methods within the context of intestinal transplantation. The versatility of MVT is emphasized, accommodating diverse organ combinations and techniques. Both isolated intestinal transplantation (IIT) and MVT have seen expanded indications, driven by improved parenteral nutrition, transplantation outcomes, and surgical innovations. Surgical techniques are tailored based on graft type, with various approaches for isolated transplantation. Preservation strategies and ostomy techniques are also covered, along with graft assessment advancements involving donor-specific antibodies. SUMMARY This review's findings underscore the remarkable evolution of MVT from experimental origins to a comprehensive clinical practice. The progress in surgical techniques and immunosuppression has broadened the spectrum of patients who can benefit from intestinal transplant, including both IIT and MVT. The expansion of indications offers hope to patients with complex gastrointestinal disorders. The detection of donor-specific antibodies in graft assessment advances diagnostic accuracy, ultimately improving patient outcomes.
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Affiliation(s)
- Phillipe Abreu
- Department of Surgery, University of Miami, Jackson Memorial Hospital, Miami Transplant Institute, Florida, USA
| | - Joao Manzi
- Department of Surgery, University of Miami, Jackson Memorial Hospital, Miami Transplant Institute, Florida, USA
- University of Sao Paulo Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Vianna
- Department of Surgery, University of Miami, Jackson Memorial Hospital, Miami Transplant Institute, Florida, USA
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11
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de Santibanes M, Ardiles V, Uño JW, Mattera J, de Santibanes E, Pekolj J. Surgical strategies to treat portal vein thrombosis during adult liver transplantation. Langenbecks Arch Surg 2023; 408:399. [PMID: 37831179 DOI: 10.1007/s00423-023-03141-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/04/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND The incidence of portal vein thrombosis (PVT) at the time of liver transplantation (LT) may be variable and underestimated. Therefore, preoperative diagnosis and stratification of its extension is so relevant for adequate surgical planning. Revascularization of the portal vein graft becomes essential for graft and patient survival after LT. Early stages of PVT may be managed with eversion thrombectomy and end-to-end anastomoses. However, severe PVT (grades 3 and 4) poses significant challenges for patients requiring LT, resulting in more complex surgeries and higher complication rates. To address these complexities, various surgical techniques have been developed, including collateral alternative vessel utilization, renoportal anastomoses, mesoportal jump graft placement, cavoportal hemitranspositions, portal vein arterialization, or even multivisceral transplantation. PURPOSE We herein describe the preoperative surgical planning as well as the different surgical strategies possible to treat portal vein thrombosis during LT. CONCLUSION A comprehensive preoperative evaluation of PVT is crucial for accurately assessing its extent and severity. This information is vital for proper surgical planning, which ultimately prepares both the surgeon and the patient for potentially complex procedures during LT. The surgical alternatives presented in this technical report offer promising solutions for treating PVT during LT, making it a viable option for selected patients.
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Affiliation(s)
- Martin de Santibanes
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina.
| | - Victoria Ardiles
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina
| | - Jimmy Walker Uño
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina
| | - Juan Mattera
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina
| | - Eduardo de Santibanes
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina
| | - Juan Pekolj
- Department of General Surgery, Hepato-Pancreato-Biliary and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Juan D. Perón 4190. C1181ACH, Buenos Aires, Argentina
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12
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Barrera-Lozano LM, Ramírez-Arbeláez JA, Muñoz CL, Becerra JA, Toro LG, Ardila CM. Portal Vein Thrombosis in Liver Transplantation: A Retrospective Cohort Study. J Clin Med 2023; 12:3951. [PMID: 37373645 PMCID: PMC10299236 DOI: 10.3390/jcm12123951] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/02/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Portal vein thrombosis was considered a contraindication for liver transplantation. This study analyzes the perioperative complications and survival of liver transplant patients with portal vein thrombosis (PVT). A retrospective observational cohort study of liver transplant patients was conducted. The outcomes were early mortality (30 days) and patient survival. A total of 201 liver transplant patients were identified and 34 (17%) patients with PVT were found. The most frequent extension of thrombosis was Yerdel 1 (58.8%), and a portosystemic shunt was identified in 23 (68%) patients. Eleven patients (33%) presented any early vascular complication, PVT being the most frequent (12%). The multivariate regression analysis showed a statistically significant association between PVT and early complications (OR = 3.3, 95% confidence interval 1.4-7.7; p = 0.006). Moreover, early mortality was observed in eight patients (24%), of which two (5.9%) presented Yerdel 2. For Yerdel 1, patient survival according to the extent of thrombosis was 75% at 1 year and 3 years, while for Yerdel 2, it was 65% at 1 year, and 50% at 3 years (p = 0.04). Portal vein thrombosis significantly influenced early vascular complications. Furthermore, portal vein thrombosis Yerdel 2 or higher impacts the survival of liver grafts in the short and long term.
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Affiliation(s)
- Luis Manuel Barrera-Lozano
- Transplant Department, Hospital San Vicente Fundación, Rionegro 054047, Colombia; (L.M.B.-L.); (J.A.R.-A.); (C.L.M.); (L.G.T.)
- Vascular Medicine Department, Faculty of Medicine, Universidad de Antioquia UdeA, Medellín 050010, Colombia
| | - Jaime Alberto Ramírez-Arbeláez
- Transplant Department, Hospital San Vicente Fundación, Rionegro 054047, Colombia; (L.M.B.-L.); (J.A.R.-A.); (C.L.M.); (L.G.T.)
| | - Cristian Leonardo Muñoz
- Transplant Department, Hospital San Vicente Fundación, Rionegro 054047, Colombia; (L.M.B.-L.); (J.A.R.-A.); (C.L.M.); (L.G.T.)
| | | | - Luis Guillermo Toro
- Transplant Department, Hospital San Vicente Fundación, Rionegro 054047, Colombia; (L.M.B.-L.); (J.A.R.-A.); (C.L.M.); (L.G.T.)
| | - Carlos M. Ardila
- Basic Studies Department, School of Dentistry, Universidad de Antioquia UdeA, Medellín 050010, Colombia
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13
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Fundora Y, Hessheimer AJ, Del Prete L, Maroni L, Lanari J, Barrios O, Clarysse M, Gastaca M, Barrera Gómez M, Bonadona A, Janek J, Boscà A, Álamo Martínez JM, Zozaya G, López Garnica D, Magistri P, León F, Magini G, Patrono D, Ničovský J, Hakeem AR, Nadalin S, McCormack L, Palacios P, Zieniewicz K, Blanco G, Nuño J, Pérez Saborido B, Echeverri J, Bynon JS, Martins PN, López López V, Dayangac M, Lodge JPA, Romagnoli R, Toso C, Santoyo J, Di Benedetto F, Gómez-Gavara C, Rotellar F, Gómez-Bravo MÁ, López Andújar R, Girard E, Valdivieso A, Pirenne J, Lladó L, Germani G, Cescon M, Hashimoto K, Quintini C, Cillo U, Polak WG, Fondevila C. Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis. J Hepatol 2023; 78:794-804. [PMID: 36690281 DOI: 10.1016/j.jhep.2023.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Yiliam Fundora
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain
| | - Amelia J Hessheimer
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain; General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Luca Del Prete
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lorenzo Maroni
- Hepatobiliary Surgery & Transplant Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, Italy
| | - Jacopo Lanari
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Oriana Barrios
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Mikel Gastaca
- Hepatobiliary Surgery & Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain
| | - Manuel Barrera Gómez
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Agnès Bonadona
- Grenoble Alpes University, CHU Grenoble Alpes, Digestive Surgery & Liver Transplantation, Grenoble, France
| | - Julius Janek
- Department of Transplant Surgery, F.D. Roosevelt Hospital, Banská Bystrica, Slovakia
| | - Andrea Boscà
- Liver Transplantation & Hepatology Laboratory, Hepatology, HPB Surgery & Transplant Unit, Health Research Institute Hospital La Fe, La Fe University Hospital, Valencia, Spain
| | | | - Gabriel Zozaya
- HPB and Liver Transplant Unit, Clínica Universidad de Navarra; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | | | - Paolo Magistri
- Hepato-pancreato-biliary Surgery & Liver Transplantation Unit, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Francisco León
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Giulia Magini
- Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Damiano Patrono
- General Surgery 2U - Liver Transplant Centre, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Jiří Ničovský
- Centrum Kardiovaskulární a Transplantační Chirurgie, Brno, Czechia
| | - Abdul Rahman Hakeem
- Department of HPB and Liver Transplant Surgery, St. James's University Hospital, Leeds, UK
| | - Silvio Nadalin
- University of Tübingen, Tübingen, Germany; European Liver and Intestine Transplant Association (ELITA) Board
| | | | - Pilar Palacios
- Hospital Clínico Universitario de Zaragoza, Zaragoza, Spain
| | - Krzysztof Zieniewicz
- Medical University of Warsaw, Warsaw, Poland; European Liver and Intestine Transplant Association (ELITA) Board
| | - Gerardo Blanco
- Hospital Universitario de Badajoz, Universidad de Extremadura, Badajoz, Spain
| | - Javier Nuño
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Baltasar Pérez Saborido
- Hepatobiliopancreatic Surgery & Liver Transplant Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Juan Echeverri
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - J Steve Bynon
- University of Texas Houston - Memorial Hermann TMC, Houston, Texas, USA
| | - Paulo N Martins
- University of Massachusetts - Memorial Medical Center, Worcester, Massachusetts, USA
| | - Víctor López López
- Department of Surgery & Transplantation, Hospital Clínico Universitario Virgen de la Arrixaca, Murcian Institue of Biosanitary Research (IMIB), Murcia, Spain
| | - Murat Dayangac
- Medipol University Hospital Center for Organ Transplantation, Istanbul, Turkey
| | - J Peter A Lodge
- Department of HPB and Liver Transplant Surgery, St. James's University Hospital, Leeds, UK
| | - Renato Romagnoli
- General Surgery 2U - Liver Transplant Centre, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Christian Toso
- Hôpitaux Universitaires de Genève, Geneva, Switzerland; European Liver and Intestine Transplant Association (ELITA) Board
| | - Julio Santoyo
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Fabrizio Di Benedetto
- Hepato-pancreato-biliary Surgery & Liver Transplantation Unit, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | | | - Fernando Rotellar
- HPB and Liver Transplant Unit, Clínica Universidad de Navarra; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | | | - Rafael López Andújar
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain; Liver Transplantation & Hepatology Laboratory, Hepatology, HPB Surgery & Transplant Unit, Health Research Institute Hospital La Fe, La Fe University Hospital, Valencia, Spain
| | - Edouard Girard
- Grenoble Alpes University, CHU Grenoble Alpes, Digestive Surgery & Liver Transplantation, Grenoble, France
| | - Andrés Valdivieso
- Hepatobiliary Surgery & Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain
| | - Jacques Pirenne
- Abdominal Transplant Surgery, UZ Leuven, KUL, Leuven, Belgium
| | - Laura Lladó
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Giacomo Germani
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy; European Liver and Intestine Transplant Association (ELITA) Board
| | - Matteo Cescon
- Hepatobiliary Surgery & Transplant Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, Italy
| | - Koji Hashimoto
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cristiano Quintini
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Umberto Cillo
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Wojciech G Polak
- Division of HPB & Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands; European Liver and Intestine Transplant Association (ELITA) Board
| | - Constantino Fondevila
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain; General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain; European Liver and Intestine Transplant Association (ELITA) Board.
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14
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Misra AC, Emamaullee J. CAQ Corner: Surgical evaluation for liver transplantation. Liver Transpl 2022; 28:1936-1943. [PMID: 35575000 PMCID: PMC9666671 DOI: 10.1002/lt.26505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/12/2022] [Accepted: 05/11/2022] [Indexed: 01/07/2023]
Abstract
The evaluation of a liver transplantation candidate is a complex and detailed process that in many cases must be done in an expedited manner because of the critically ill status of some patients with end-stage liver disease. It involves great effort from and the collaboration of multiple disciplines, and during the evaluation several studies and interventions are performed to assess and potentially prepare a patient for liver transplant. Here we review the liver transplantation evaluation from a surgical perspective.
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Affiliation(s)
- Asish C. Misra
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of SurgeryUniversity of Southern CaliforniaLos AngelesCaliforniaUSA,Division of Hepatobiliary and Abdominal Organ Transplantation SurgeryChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
| | - Juliet Emamaullee
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of SurgeryUniversity of Southern CaliforniaLos AngelesCaliforniaUSA,Division of Hepatobiliary and Abdominal Organ Transplantation SurgeryChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
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15
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Splanchnic vein thrombosis associated with myeloproliferative neoplasms. Thromb Res 2022; 218:8-16. [PMID: 35963121 DOI: 10.1016/j.thromres.2022.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/30/2022] [Accepted: 08/03/2022] [Indexed: 11/22/2022]
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16
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Livingstone J, Raveh Y, Souki F, Shatz V, Shah R, Ibrahim T, Shuman M, Beduschi T, Vianna R, Alvarez R, Nicolau-Raducu R. Multivisceral Transplant in a Patient With Portopulmonary Hypertension: A Case Report. Transplant Proc 2022; 54:1664-1670. [PMID: 35914967 DOI: 10.1016/j.transproceed.2022.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/14/2022] [Indexed: 11/18/2022]
Abstract
Portopulmonary hypertension, a type of pulmonary arterial hypertension in the setting of cirrhotic or noncirrhotic portal hypertension, is associated with elevated morbidity and mortality during and after transplantation. Uncontrolled portopulmonary hypertension may prevent or delay listing for transplant candidates, and the prognosis without treatment and ultimately transplant is extremely poor. We present a 29-year-old White woman, who had a post-liver transplant at infancy due to biliary atresia. Later on, she developed extensive portal vein thrombosis and portopulmonary hypertension and underwent a multivisceral transplant (liver, stomach, pancreaticoduodenal complex, and small and large intestine). Preoperative mean pulmonary artery pressure was <30 mm Hg with a pulmonary vascular resistance of <300 dynes.s/cm5 on oral sildenafil and intravenous epoprostenol. Intraoperatively, management required comprehensive transfusion protocols, a careful balance between correcting blood loss and preventing thrombosis. Intravenous epoprostenol, sildenafil, milrinone, and inhaled nitric oxide were used to reduce elevated mean pulmonary artery pressure and right ventricular strain associated with vascular clamping, reperfusion, and massive fluid shifts. Nitric oxide and epoprostenol use unleashed antiplatelet effects on a patient already susceptible to coagulopathy. A multimodal and multidisciplinary approach continued throughout the surgery and in the postoperative period, which led to a successful outcome.
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Affiliation(s)
- J Livingstone
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Y Raveh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - F Souki
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - V Shatz
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Shah
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida; Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - T Ibrahim
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - M Shuman
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - T Beduschi
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida; Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Vianna
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida; Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Alvarez
- Department of Medicine, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Nicolau-Raducu
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida.
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17
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Ivanics T, Vianna R, Kubal CA, Iyer KR, Mazariegos GV, Matsumoto CS, Mangus R, Beduschi T, Abouljoud M, Fridell JA, Nagai S. Impact of the acuity circle model for liver allocation on multivisceral transplant candidates. Am J Transplant 2022; 22:464-473. [PMID: 34403552 DOI: 10.1111/ajt.16803] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/22/2021] [Accepted: 08/11/2021] [Indexed: 01/25/2023]
Abstract
Liver allocation was updated on February 4, 2020, replacing a Donor Service Area (DSA) with acuity circles (AC). The impact on waitlist outcomes for patients listed for combined liver-intestine transplantation (multivisceral transplantation [MVT]) remains unknown. The Organ Procurement and Transplantation Network/United Network for Organ Sharing database was used to identify all candidates listed for both liver and intestine between January 1, 2018 and March 5, 2021. Two eras were defined: pre-AC (2018-2020) and post-AC (2020-2021). Outcomes included 90-day waitlist mortality and transplant probability. A total of 127 adult and 104 pediatric MVT listings were identified. In adults, the 90-day waitlist mortality was not statistically significantly different, but transplant probability was lower post-AC. After risk-adjustment, post-AC was associated with a higher albeit not statistically significantly different mortality hazard (sub-distribution hazard ratio[sHR]: 8.45, 95% CI: 0.96-74.05; p = .054), but a significantly lower transplant probability (sHR: 0.33, 95% CI: 0.15-0.75; p = .008). For pediatric patients, waitlist mortality and transplant probability were similar between eras. The proportion of patients who underwent transplant with exception points was lower post-AC both in adult (44% to 9%; p = .04) and pediatric recipients (65% to 15%; p = .002). A lower transplant probability observed in adults listed for MVT may ultimately result in increased waitlist mortality. Efforts should be taken to ensure equitable organ allocation in this vulnerable patient population.
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Affiliation(s)
- Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA.,Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
| | - Rodrigo Vianna
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, Florida, USA
| | - Chandrashekhar A Kubal
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kishore R Iyer
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cal S Matsumoto
- Medstar Georgetown University Hospital, Medstar Georgetown Transplant Institute, Washington, DC, USA
| | - Richard Mangus
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thiago Beduschi
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA
| | - Jonathan A Fridell
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA
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18
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Duchateau NM, Canovai E, Vianna RM, Vanuytsel T, Verslype C, Mazariegos GV, Monbaliu D, Pirenne J, Ceulemans LJ. Combined liver-intestinal and multivisceral transplantation for neuroendocrine tumors extending beyond the liver: A systematic literature review. Transplant Rev (Orlando) 2022; 36:100678. [DOI: 10.1016/j.trre.2022.100678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 10/19/2022]
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19
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Clarysse M, Wilmer A, Debaveye Y, Laleman W, Devos T, Canovai E, Verslype C, van der Merwe S, van Malenstein H, Nevens F, Maleux G, Sainz-Barriga M, Monbaliu D, Pirenne J. Recanalization of portal axis after cavoportal hemitransposition in a liver transplant recipient with complete splanchnic thrombosis. Pediatr Transplant 2021; 25:e14097. [PMID: 34289227 DOI: 10.1111/petr.14097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Diffuse splanchnic thrombosis may render standard LTx difficult or even technically impossible. A 19-year-old woman with acute-on-chronic Budd-Chiari syndrome and complete splanchnic thrombosis underwent conventional LTx. Only limited anatomical portal inflow could be restored, and urgent re-transplantation for recurrent splanchnic vein thrombosis became necessary. METHODS At re-transplant, and in addition to the reestablishment of some portal inflow through the preserved original porto (native)-portal (graft) connection, a cavoportal shunt was created (first partial via 30% tapering of the vena cava, but eventually complete by total occlusion of the vena cava). RESULTS The postoperative course was then uneventful, and interestingly, the native portomesenteric axis gradually reopened. Two years post-transplant, the liver graft is perfused via both physiological and non-physiological sources. Liver function is normal. There is no IVC syndrome and no residual PHT. She is leading a normal life. CONCLUSION Creation of CPHT, in addition to the preservation of portal inflow from the native splanchnic system, should be considered in patients with diffuse splanchnic thrombosis, when sufficient physiological portal inflow cannot be restored at the time of LTx, but in whom the splanchnic circulation may reopen up later.
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Affiliation(s)
- Mathias Clarysse
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Alexander Wilmer
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium.,Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Yves Debaveye
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Hepatology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Timothy Devos
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Molecular Immunology (Rega Institute), Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Emilio Canovai
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Chris Verslype
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Clinical Digestive Oncology, Department of Digestive Oncology, KU Leuven, Leuven, Belgium
| | - Schalk van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Hepatology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Hannah van Malenstein
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Hepatology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Hepatology, Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, Section of Interventional Radiology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Radiology, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Mauricio Sainz-Barriga
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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20
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Kotsifa E, Kykalos S, Machairas N, Nikiteas N, Sotiropoulos GC. Management of portal vein thrombosis in cirrhotic patients enlisted for liver transplantation: From diagnosis to treatment (Review). Biomed Rep 2021; 15:94. [PMID: 34631049 DOI: 10.3892/br.2021.1470] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 07/28/2021] [Indexed: 12/11/2022] Open
Abstract
Portal vein thrombosis (PVT) commonly occurs in patients with cirrhosis. Several classification systems of PVT have been proposed over the years reflecting the challenge in establishing a widely accepted system. To date, PVT has been considered an absolute contraindication for orthotopic liver transplantation (OLT) since it is associated with decreased graft survival and increased patient mortality. Nevertheless, the development of modern surgical techniques has enabled the inclusion of these candidates in OLT waiting lists, since their postoperative results are shown to be comparable to those of patients without PVT. The aim of the present review was to critically appraise the available treatment options for cirrhotic patients enlisted for liver transplantation in the setting of PVT.
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Affiliation(s)
- Evgenia Kotsifa
- Second Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Stylianos Kykalos
- Second Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos Machairas
- Second Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos Nikiteas
- Second Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Georgios C Sotiropoulos
- Second Department of Propaedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
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21
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Pinelli D, Camagni S, Amaduzzi A, Frosio F, Fontanella L, Carioli G, Guizzetti M, Zambelli MF, Giovanelli M, Fagiuoli S, Colledan M. Liver transplantation in patients with non-neoplastic portal vein thrombosis: 20 years of experience in a single center. Clin Transplant 2021; 36:e14501. [PMID: 34633110 DOI: 10.1111/ctr.14501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/14/2021] [Accepted: 09/25/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND The Yerdel classification is widely used for describing the severity of portal vein thrombosis (PVT) in liver transplant (LT) candidates, but might not accurately predict transplant outcome. METHODS We retrospectively analyzed data regarding 97 adult patients with PVT who underwent LT, investigating whether the complexity of portal reconstruction could better correlate with transplant outcome than the site and extent of the thrombosis. RESULTS 79/97 (80%) patients underwent thrombectomy and anatomical anastomosis (TAA), 18/97 (20%) patients underwent non-anatomical physiological reconstructions (non-TAA). PVT Yerdel grade was 1-2 in 72/97 (74%) patients, and 3-4 in 25/97 (26%) patients. Univariate analysis revealed higher 30-day mortality, 90-day mortality, 1-year mortality, and a higher rate of severe early complications in the non-TAA group than in the TAA group (p = .018, .001, .014, .009, respectively). In the model adjusted for PVT Yerdel grade, non-TAA remained independently associated with higher 30-day, 90-day, and 1-year mortality (p = .021, .007, and .015, respectively). The portal vein re-thrombosis and overall patient and graft survival rates were similar. DISCUSSION In our experience, the complexity of portal reconstruction better correlated with transplant outcome than the Yerdel classification, which did not even appear to be a reliable predictor of the surgical complexity and technique.
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Affiliation(s)
- Domenico Pinelli
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Stefania Camagni
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Annalisa Amaduzzi
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Fabio Frosio
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Laura Fontanella
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Greta Carioli
- FROM Research Foundation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Michela Guizzetti
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - Mara Giovanelli
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Stefano Fagiuoli
- Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Michele Colledan
- Department of Organ Failure and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
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22
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Liou P, Kato T, Fishbein T. Surgical Perspectives on the American Association for the Study of Liver Diseases Guideline for Anticoagulation and Implications for Liver Transplantation. Liver Transpl 2021; 27:580-583. [PMID: 37160043 DOI: 10.1002/lt.25990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Peter Liou
- Center for Liver Disease and Transplantation, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Tomoaki Kato
- Center for Liver Disease and Transplantation, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Thomas Fishbein
- Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
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23
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Canovai E, Ceulemans LJ, Gilbo N, Duchateau NM, De Hertogh G, Hiele M, Jochmans I, Vanuytsel T, Maleux G, Verhaegen M, Monbaliu D, Pirenne J. Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis: Lessons Learned for Surgical Optimization. Front Surg 2021; 8:645302. [PMID: 33681286 PMCID: PMC7933591 DOI: 10.3389/fsurg.2021.645302] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/28/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Multivisceral transplantation entails the en-bloc transplantation of stomach, duodenum, pancreas, liver and bowel following resection of the native organs. Diffuse portomesenteric thrombosis, defined as the complete occlusion of the portal system, can lead to life-threatening gastrointestinal bleeding, malnutrition and can be associated with liver and intestinal failure. Multivisceral transplantation is the only procedure that offers a definitive solution by completely replacing the portal system. However, this procedure is technically challenging in this setting. The aim of this study is to describe our experience, highlight the challenges and propose technical solutions. Materials and Methods: We performed a retrospective analysis of our cohort undergoing multivisceral transplantation for diffuse portomesenteric thrombosis at our institution from 2000 to 2020. Donor and recipient demographics and surgical strategies were reviewed in detail and posttransplant complications and survival were analyzed. Results: Five patients underwent MVTx. Median age was 47 years (23–62). All had diffuse portomesenteric thrombosis with life-threatening variceal bleeding. Major blood loss during exenteration was avoided by combining two techniques: embolization of the native organs followed by a novel, staged extraction. This prevented major perioperative blood loss [median intra-operative transfusion of 3 packed red blood cell units (0–5)]. Median CIT was 330 min (316–416). There was no perioperative death. One patient died due to invasive aspergillosis. Four others are alive and well with a median follow-up of 4.1 years (0.3–5.9). Conclusions: Multivisceral transplantation should be considered in patients with diffuse portomesenteric thrombosis that cannot be treated by any other means. We propose a standardized surgical approach to limit the operative risk and improve the outcome.
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Affiliation(s)
- Emilio Canovai
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Laurens J Ceulemans
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Chronic Diseases, Metabolism and Ageing, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Nicholas Gilbo
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Nicolas M Duchateau
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Gert De Hertogh
- Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Martin Hiele
- Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Geert Maleux
- Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Marleen Verhaegen
- Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
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24
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Varkey J. Graft assessment for acute rejection after intestinal transplantation: current status and future perspective. Scand J Gastroenterol 2021; 56:13-19. [PMID: 33202155 DOI: 10.1080/00365521.2020.1847318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Intestinal transplantation has since its inception evolved as a lifesaving treatment option for patients with irreversible intestinal failure who can no longer be sustained on parenteral nutrition. Improvement in short-term survival after transplantation has also justified the expansion of treatment indications. Unfortunately, success is somewhat limited by a plateau observed in long-term survival. The reason for this sub-optimal long-term result experienced in this cohort may in part be attributed to the intestinal graft with the lymphoid content it carries inflicting the host with multiple complications where acute cellular rejection is one of the most common causes for graft loss. Graft monitoring is for this reason of paramount importance and detection of rejection at an early stage essential to enable early instigation of treatment and successful reversal of the pathology. Due to the challenges in diagnosing acute rejection with a noninvasive marker we are still limited to a surveillance protocol using endoscopy and biopsies for the diagnosis of rejection. The purpose of our paper is to review the adequacy of different methods in monitoring the graft for acute rejection using biomarkers, endoscopy and imaging. In conclusion, the evidence base continues to support the use of histology for the diagnosis of acute rejection. The role of biomarkers are still debatable, although markers such as calprotectin might be beneficial in excluding an ongoing process.
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Affiliation(s)
- Jonas Varkey
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sahlgrenska Intestinal Failure and Transplant Centre, Gothenburg, Sweden
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25
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Rugivarodom M, Charatcharoenwitthaya P. Nontumoral Portal Vein Thrombosis: A Challenging Consequence of Liver Cirrhosis. J Clin Transl Hepatol 2020; 8:432-444. [PMID: 33447527 PMCID: PMC7782107 DOI: 10.14218/jcth.2020.00067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/27/2020] [Accepted: 10/18/2020] [Indexed: 12/13/2022] Open
Abstract
Nontumoral portal vein thrombosis (PVT) is an increasingly recognized complication in patients with cirrhosis. Substantial evidence shows that portal flow stasis, complex thrombophilic disorders, and exogenous factors leading to endothelial dysfunction have emerged as key factors in the pathogenesis of PVT. The contribution of PVT to hepatic decompensation and mortality in cirrhosis is debatable; however, the presence of an advanced PVT increases operative complexity and decreases survival after transplantation. The therapeutic decision for PVT is often determined by the duration and extent of thrombosis, the presence of symptoms, and liver transplant eligibility. Evidence from several cohorts has demonstrated that anticoagulation treatment with vitamin K antagonist or low molecular weight heparin can achieve recanalization of the portal vein, which is associated with a reduction in portal hypertension-related events and improved survival in cirrhotic patients with PVT. Consequently, interest in direct oral anticoagulants for PVT is increasing, but clinical data in cirrhosis are limited. Although the most feared consequence of anticoagulation is bleeding, most studies indicate that anticoagulation therapy for PVT in cirrhosis appears relatively safe. Interestingly, the data showed that transjugular intrahepatic portosystemic shunt represents an effective adjunctive therapy for PVT in cirrhotic patients with symptomatic portal hypertension if anticoagulation is ineffective. Insufficient evidence regarding the optimal timing, modality, and duration of therapy makes nontumoral PVT a challenging consequence of cirrhosis. In this review, we summarize the current literature and provide a potential algorithm for the management of PVT in patients with cirrhosis.
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Affiliation(s)
- Manus Rugivarodom
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Correspondence to: Phunchai Charatcharoenwitthaya, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Wang-Lang Road, Bangkoknoi, Bangkok 10700, Thailand. Tel: +662-419-7282, Fax: +662-411-5013, E-mail:
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26
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New Insights Into the Indications for Intestinal Transplantation: Consensus in the Year 2019. Transplantation 2020; 104:937-946. [PMID: 31815899 DOI: 10.1097/tp.0000000000003065] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In 2001, a Statement was published that described indications for intestinal transplantation in patients with intestinal failure expected to require parenteral nutrition indefinitely. Since 2001, advances in the management of intestinal failure including transplantation and patient survival, both on extended parenteral nutrition and after transplantation, have improved, leading to a reduction in the number of intestinal transplants worldwide from a peak of 270 per year in 2008 to 149 per year in 2017. These changes suggest that the original 2001 Statement requires reassessment. All patients with permanent intestinal failure should be managed by dedicated multidisciplinary intestinal rehabilitation teams. Under care of these teams, patients should be considered for intestinal transplantation in the event of progressive intestinal failure-associated liver disease, progressive loss of central vein access, and repeated life-threatening central venous catheter-associated infections requiring critical care. Additional indications for transplantation include large desmoid tumors and other intra-abdominal tumors with reasonable expectation of posttransplant cure, extensive mesenteric vein thrombosis and intestinal infarction, total intestinal aganglionosis, and nonrecoverable congenital secretory diarrhea. Quality of life typically improves after successful intestinal transplantation and may support the decision to proceed with transplantation when other indications are present. However, the requirement for life-long immunosuppression and its associated side effects preclude intestinal transplantation if motivated only by an expectation of improved quality of life. Increasing experience with intestinal transplantation and critical appraisal of transplant outcomes including graft survival and patient quality of life together with potential advances in immunosuppression can be expected to influence transplant practices in the future.
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27
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28
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Sharshar M, Yagi S, Iida T, Yao S, Miyachi Y, Macshut M, Iwamura S, Hirata M, Ito T, Hata K, Taura K, Okajima H, Kaido T, Uemoto S. Liver transplantation in patients with portal vein thrombosis: A strategic road map throughout management. Surgery 2020; 168:1160-1168. [PMID: 32861438 DOI: 10.1016/j.surg.2020.07.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/06/2020] [Accepted: 07/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Liver transplantation in the setting of portal vein thrombosis is an intricate issue that occasionally necessitates extraordinary procedures for portal flow restoration. However, to date, there is no consensus on a persistent management strategy, particularly with extensive forms. This work aims to introduce our experience-based surgical management algorithm for portal vein thrombosis during liver transplantation and to clarify some of the debatable circumstances associated with this problematic issue. METHODS Between 2006 and 2019, 494 adults underwent liver transplantation at our institute. Ninety patients had preoperative portal vein thrombosis, and 79 patients underwent living donor liver transplantation. Our algorithm trichotomized the management plan into 3 pathways based on portal vein thrombosis grade. The surgical procedures implemented included thrombectomy, interposition vein grafts, jump grafts from the superior mesenteric vein, jump grafts from a collateral and renoportal anastomosis in 56, 13, 11, 4, and 2 patients, respectively. Four patients with mural thrombi did not require any special intervention. RESULTS Thirteen patients experienced posttransplant portal vein complications. They all proved to have a patent portal vein by the end of follow-up regardless of the management modality. No significant survival difference was observed between cohorts with versus without portal vein thrombosis. The early graft loss rate was significantly higher with advanced grades (P = .048) as well as technically demanding procedures (P = .032). CONCLUSION A stepwise broad-minded strategy should always be adopted when approaching advanced portal vein thrombosis during liver transplantation. An industrious preoperative evaluation should always be carried out to locate the ideal reliable source for portal flow restoration.
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Affiliation(s)
- Mohamed Sharshar
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Hepato-Pancreato-Biliary Surgery, National Liver Institute, Menoufia University, Shebin El kom, Egypt
| | - Shintaro Yagi
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Taku Iida
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Siyuan Yao
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Miyachi
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mahmoud Macshut
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Hepato-Pancreato-Biliary Surgery, National Liver Institute, Menoufia University, Shebin El kom, Egypt
| | - Sena Iwamura
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaaki Hirata
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Ito
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichiro Hata
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kojiro Taura
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshimi Kaido
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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29
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Tekin A, Beduschi T, Vianna R, Mangus RS. Multivisceral transplant as an option to transplant cirrhotic patients with severe portal vein thrombosis. Int J Surg 2020; 82S:115-121. [PMID: 32739540 DOI: 10.1016/j.ijsu.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/15/2022]
Abstract
Non-tumoral portal vein thrombosis (PVT) is a critical complication in the patient with advanced cirrhosis awaiting liver transplantation (LT). With the evolution of liver transplant (LT) technique, PVT has morphed from an absolute contraindication to a relative contraindication, depending on the grade of the thrombus. The Yerdel classification is one system of grading PVT severity. Patients with Yerdel class 1-3 PVT can undergo LT at centers with experience in complex portal vein (PV) dissection, thrombectomy, and reconstruction. Class 4 PVT, however, is even more complex and may require heroic techniques such as cavoportal hemitransposition, PV arterialization or multivisceral transplant (MVT). Some centers use a MVT back-up approach for patients with Yerdel class 4 PVT. In these patients, all organs with PV outflow are procured simultaneously as a cluster graft from a deceased donor (liver, pancreas, intestine±stomach). If physiologic PV inflow is established intraoperatively, the recipient undergoes LT. Otherwise the MVT graft is transplanted. MVT establishes physiologic PV flow, but transplantation of the intestine confers significant lifelong risks including rejection, graft-versus host disease and post-transplant lymphoma. Yerdel class 1-4 PVT patients undergoing successful LT have 5-year survival similar to non-PVT patients, while patients requiring full MVT experience somewhat higher mortality because of the complexity of the surgery and medical management.
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Teng F, Sun KY, Fu ZR. Tailored classification of portal vein thrombosis for liver transplantation: Focus on strategies for portal vein inflow reconstruction. World J Gastroenterol 2020; 26:2691-2701. [PMID: 32550747 PMCID: PMC7284174 DOI: 10.3748/wjg.v26.i21.2691] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/25/2020] [Accepted: 04/21/2020] [Indexed: 02/06/2023] Open
Abstract
Portal vein thrombosis (PVT) is currently not considered a contraindication for liver transplantation (LT), but diffuse or complicated PVT remains a major surgical challenge. Here, we review the prevalence, natural course and current grading systems of PVT and propose a tailored classification of PVT in the setting of LT. PVT in liver transplant recipients is classified into three types, corresponding to three portal reconstruction strategies: Anatomical, physiological and non-physiological. Type I PVT can be removed via low dissection of the portal vein (PV) or thrombectomy; porto-portal anastomosis is then performed with or without an interposed vascular graft. Physiological reconstruction used for type II PVT includes vascular interposition between mesenteric veins and PV, collateral-PV and splenic vein-PV anastomosis. Non-physiological reconstruction used for type III PVT includes cavoportal hemitransposition, renoportal anastomosis, portal vein arterialization and multivisceral transplantation. All portal reconstruction techniques were reviewed. This tailored classification system stratifies PVT patients by surgical complexity, risk of postoperative complications and long-term survival. We advocate using the tailored classification for PVT grading before LT, which will urge transplant surgeons to make a better preoperative planning and pay more attention to all potential strategies for portal reconstruction. Further verification in a large-sample cohort study is needed.
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Affiliation(s)
- Fei Teng
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
| | - Ke-Yan Sun
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
| | - Zhi-Ren Fu
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Navy Medical University, Shanghai 200003, China
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Human norovirus targets enteroendocrine epithelial cells in the small intestine. Nat Commun 2020; 11:2759. [PMID: 32488028 PMCID: PMC7265440 DOI: 10.1038/s41467-020-16491-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 05/02/2020] [Indexed: 12/21/2022] Open
Abstract
Human noroviruses are a major cause of diarrheal illness, but pathogenesis is poorly understood. Here, we investigate the cellular tropism of norovirus in specimens from four immunocompromised patients. Abundant norovirus antigen and RNA are detected throughout the small intestinal tract in jejunal and ileal tissue from one pediatric intestinal transplant recipient with severe gastroenteritis. Negative-sense viral RNA, a marker of active viral replication, is found predominantly in intestinal epithelial cells, with chromogranin A-positive enteroendocrine cells (EECs) identified as a permissive cell type in this patient. These findings are consistent with the detection of norovirus-positive EECs in the other three immunocompromised patients. Investigation of the signaling pathways induced in EECs that mediate communication between the gut and brain may clarify mechanisms of pathogenesis and lead to the development of in vitro model systems in which to evaluate norovirus vaccines and treatment. Human norovirus pathogenesis is incompletely understood due to a lack of appropriate animal disease models. Here, Green et al. show norovirus replication in chromogranin A-positive enteroendocrine cells and other epithelial cells in tissue from a pediatric intestinal transplant recipient with severe gastroenteritis.
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Bhangui P, Fernandes ESM, Di Benedetto F, Joo DJ, Nadalin S. Current management of portal vein thrombosis in liver transplantation. Int J Surg 2020; 82S:122-127. [PMID: 32387201 DOI: 10.1016/j.ijsu.2020.04.068] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/15/2020] [Accepted: 04/28/2020] [Indexed: 02/07/2023]
Abstract
Nontumoral portal vein thrombosis (PVT) is present at liver transplantation (LT) in 5-26% of cirrhotic patients, and is known to affect post LT outcomes. Up to 31% of patients who are found to have PVT at the time of LT, would have had PVT at the time of initial listing, but others develop PVT during the waiting period. Adequate screening and treatment of the PVT on the waiting list for LT is thus essential so that a portoportal anastomoses can be performed at the time of LT. Early PVT (Yerdel Grade I/II) can be usually managed by thrombectomy, whereas Grade III PVT may require a jump graft from the superior mesenteric vein to the graft PV. Complete portomesenteric thrombosis is a huge challenge, and sometimes a cause for denying a LT in these patients, with multivisceral transplant being the only alternative. The presence of spontaneous, or previously surgically created portosytemic shunts like the leinorenal shunt, may serve as a good inflow option (renoportal anastomosis) in these patients to establish a physiological reconstruction. Although challenging, good outcomes are possible in patients with complex PVT if the appropriate surgical technique is chosen to ensure portal inflow and resolution of PHT post LT.
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Affiliation(s)
- Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi-NCR, India.
| | - Eduardo S M Fernandes
- Department of Gastrointestinal Surgery - Rio de Janeiro Federal University and Liver Transplant Unit - São Lucas Hospital RJ, Brazil
| | - Fabrizio Di Benedetto
- HPB Surgery and Liver Transplant Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Dong-Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Silvio Nadalin
- Department of General, Visceral and Transplantation Surgery, University Hospital Tuebingen, Tübingen, Germany
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Puri Y, Gunasekaran V, Palanisamy SK, Elangovan B, Krishna P, Balasubramanian B, Ananth A, Reddy MS, Rela M. A Novel Technique of Physiological Portal Inflow Augmentation During Liver Transplantation for Yerdel Grade 4 Portal Vein Thrombosis. Liver Transpl 2020; 26:294-298. [PMID: 31724287 DOI: 10.1002/lt.25680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/29/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Yogesh Puri
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | | | - Shiva Kumar Palanisamy
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Babu Elangovan
- Department of Surgical Gastroenterology and Liver Transplant, Sri Ramachandra Medical College and Research Institute, Chennai, India
| | - Pradeep Krishna
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Balaji Balasubramanian
- Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Anjana Ananth
- Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Mettu Srinivas Reddy
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Mohamed Rela
- HPB Surgery and Liver Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
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Mangus RS. Liver-Intestine/Multivisceral Perspective: Indications, Patient Selection, and Allocation Policy. Clin Liver Dis (Hoboken) 2019; 14:142-145. [PMID: 31709042 PMCID: PMC6832100 DOI: 10.1002/cld.848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 05/28/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Richard S. Mangus
- Department of Surgery, Transplant DivisionIndiana University School of MedicineIndianapolisIN
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Bhangui P, Lim C, Levesque E, Salloum C, Lahat E, Feray C, Azoulay D. Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation. J Hepatol 2019; 71:1038-1050. [PMID: 31442476 DOI: 10.1016/j.jhep.2019.08.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/25/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023]
Abstract
Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.
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Affiliation(s)
- Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, New Delhi, India
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Paris, France
| | - Eric Levesque
- Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel
| | - Cyrille Feray
- Department of Hepatology, Paul Brousse Hospital, Villejuif, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France; Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel.
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Elsabbagh AM, Hawksworth J, Khan KM, Kaufman SS, Yazigi NA, Kroemer A, Smith C, Fishbein TM, Matsumoto CS. Long-term survival in visceral transplant recipients in the new era: A single-center experience. Am J Transplant 2019; 19:2077-2091. [PMID: 30672105 PMCID: PMC6591067 DOI: 10.1111/ajt.15269] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/31/2018] [Accepted: 01/14/2019] [Indexed: 02/06/2023]
Abstract
There is a paucity of data on long-term outcomes following visceral transplantation in the contemporary era. This is a single-center retrospective analysis of all visceral allograft recipients who underwent transplant between November 2003 and December 2013 with at least 3-year follow-up data. Clinical data from a prospectively maintained database were used to assess outcomes including patient and graft survival. Of 174 recipients, 90 were adults and 84 were pediatric patients. Types of visceral transplants were isolated intestinal transplant (56.3%), combined liver-intestinal transplant (25.3%), multivisceral transplant (16.1%), and modified multivisceral transplant (2.3%). Three-, 5-, and 10-year overall patient survival was 69.5%, 66%, and 63%, respectively, while 3-, 5-, and 10-year overall graft survival was 67%, 62%, and 61%, respectively. In multivariable analysis, significant predictors of survival included pediatric recipient (P = .001), donor/recipient weight ratio <0.9 (P = .008), no episodes of severe acute rejection (P = .021), cold ischemia time <8 hours (P = .014), and shorter hospital stay (P = .0001). In conclusion, visceral transplantation remains a good option for treatment of end-stage intestinal failure with parenteral nutritional complications. Proper graft selection, shorter cold ischemia time, and improvement of immunosuppression regimens could significantly improve the long-term survival.
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Affiliation(s)
- Ahmed M. Elsabbagh
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC,Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt,St. Vincent Abdominal Transplant Center, St. Vincent Hospital, Indianapolis, Indiana
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC,Department of Surgery, Organ Transplant Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Khalid M. Khan
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Stuart S. Kaufman
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Nada A. Yazigi
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Coleman Smith
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
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Xue Z, Zhang X, Li Z, Deng R, Wu L, Ma Y. Analysis of portal vein thrombosis after liver transplantation. ANZ J Surg 2019; 89:1075-1079. [PMID: 31087535 DOI: 10.1111/ans.15242] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 03/05/2019] [Accepted: 03/25/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Zhicheng Xue
- Department of Organ TransplantationThe First Affiliated Hospital of Sun Yat‐sen University Guangzhou China
| | - Xuzhi Zhang
- Department of Organ TransplantationThe First Affiliated Hospital of Sun Yat‐sen University Guangzhou China
| | - Zhongqiu Li
- Department of Organ TransplantationThe First Affiliated Hospital of Sun Yat‐sen University Guangzhou China
| | - Ronghai Deng
- Department of Organ TransplantationThe First Affiliated Hospital of Sun Yat‐sen University Guangzhou China
| | - Linwei Wu
- Department of Organ TransplantationThe First Affiliated Hospital of Sun Yat‐sen University Guangzhou China
| | - Yi Ma
- Department of Organ TransplantationThe First Affiliated Hospital of Sun Yat‐sen University Guangzhou China
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38
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Intagliata NM, Caldwell SH, Tripodi A. Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology 2019; 156:1582-1599.e1. [PMID: 30771355 DOI: 10.1053/j.gastro.2019.01.265] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/11/2019] [Accepted: 01/21/2019] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis unrelated to solid malignancy is common in patients with cirrhosis, but less frequently observed in patients without cirrhosis. Prompt diagnosis and management of acute symptomatic portal vein thrombosis are essential. Failure to detect and treat thromboses can result in mesenteric ischemia, chronic cavernous transformation, and complications of portal hypertension. In patients with cirrhosis, development of portal vein thrombosis is often insidious and remains undetected until its incidental detection. Management of portal vein thrombosis in patients with cirrhosis is more controversial. However, there are data to support treatment of specific patients with anticoagulation agents. We review the common and distinct features of portal vein thromboses in patients without liver tumors, with and without cirrhosis.
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Affiliation(s)
- Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia Medical CenterCharlottesville, Virginia.
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Medical CenterCharlottesville, Virginia
| | - Armando Tripodi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
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Abstract
BACKGROUND This study reports the infection rate, location of infection and pathogen causing bacterial, fungal or viral infections in intestine transplant recipients at a pediatric transplant center. METHODS Records from a pediatric center were reviewed for patients receiving an intestine transplant. Positive cultures and pathology reports were used to diagnose bacterial, fungal and viral infections and also to determine location and infectious agent. Risk for infection was assessed based on liver or colon inclusion, and immunosuppression induction, as part of the intestine transplant. RESULTS During the study period, 52 intestine transplants were performed on 46 patients. Bacterial, fungal and viral infection rates were 90%, 25% and 75%, respectively. Enterococcus spp. (non-vancomycin-resistant enterococci) were the most common pathogens and were isolated from 52% of patients. Non-vancomycin-resistant enterococci was present in 12% of transplant recipients. Candida spp. were the most common fungal pathogens (23% of patients). Respiratory viral infections were common (44%), and Cytomegalovirus infection rate was 17%. Common sites of infection were bloodstream, urinary and upper respiratory tract. Colon and liver inclusion in the transplant graft was not associated with increased risk of infection, nor was addition of rituximab to the immunosuppression induction protocol. CONCLUSIONS Postintestine transplant infections are ubiquitous in the pediatric population, including high rates of infection from bacterial, viral and fungal sources. Inclusion of the liver and/or colon as a component of the transplant graft did not appear to greatly impact the infectious risk. Adding rituximab to the immunosuppression induction protocol did not impact on infectious risk.
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40
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41
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Clouse JW, Kubal CA, Fridell JA, Pearsall EJ, Mangus RS. Post-intestine transplant graft-vs-host disease associated with inclusion of a liver graft and with a high mortality risk. Clin Transplant 2018; 33:e13409. [PMID: 30222903 DOI: 10.1111/ctr.13409] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 04/19/2018] [Accepted: 09/10/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION This study reports the incidence, anatomic location, and outcomes of graft-vs-host disease (GVHD) at a single active intestine transplant center. METHODS Records were reviewed for all patients receiving an intestine transplant from 2003 to 2015. Pathology reports and pharmacy records were reviewed to establish the diagnosis, location, and therapeutic interventions for GVHD. RESULTS A total of 236 intestine transplants were performed during the study period, with 37 patients (16%) developing GVHD. The median time to onset of disease was 83 days, with 89% of affected patients diagnosed in the first year post-transplant. Mortality for affected patients was 54% in the 1 year after GVHD diagnosis. Skin lesions were the most common manifestation of GVHD. Other sites of disease included lungs, bone marrow, oral mucosa, large intestine, and brain. The incidence of GVHD was 16% in adult patients, and slightly lower in pediatric recipients (13%). In adults, increasing graft volume (isolated vs multi-organ) and liver inclusion were associated with increasing risk of GVHD, though this was not seen in pediatric patients. CONCLUSION Overall, 16% of intestine transplant recipients developed GVHD. GVHD is associated with high mortality, and disease in the lungs, brain, and bone marrow was universally fatal.
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Affiliation(s)
- Jared W Clouse
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chandrashekhar A Kubal
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan A Fridell
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, Indiana
| | - E Jordan Pearsall
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, Indiana
| | - Richard S Mangus
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, Indiana
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Ekser B, Kubal CA, Fridell JA, Mangus RS. Comparable outcomes in intestinal retransplantation: Single-center cohort study. Clin Transplant 2018; 32:e13290. [PMID: 29782661 DOI: 10.1111/ctr.13290] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Graft loss in intestinal transplantation (ITx) is close to 25% in the first year and 50% at 5-year post-transplantation. Although technically and immunologically challenging, intestinal retransplantation is now the 4th most common indication for ITx. METHODS The aim of this study was to review and compare the outcomes of intestinal retransplantation with primary ITx, which included isolated ITx, modified multivisceral transplantation (mMVTx), and full MVTx, between 2003 and 2014 at Indiana University. RESULTS Of 218 ITx, 18 (8.3%) were retransplantation. Causes of graft loss were rejection(78%), pancreatitis (11%), and severe intestine dismotility (11%). MVTx (16/18, 89%) was the preferred retransplantation option. In 7 (39%) patients, graftectomy was performed between primary and intestinal retransplantation. Median interval between primary ITx and retransplantation was 421 days. Although patient and graft survival rates at 1 year, 3 years, and 5 years were comparable between primary and retransplants, the number of retransplants was limited in the follow-up after post-transplant year 3. CONCLUSIONS We identified that timing of retransplantation, graftectomy prior to retransplant allowing an immunosuppression free state, inclusion of the liver, and preserved renal function are important factors in the consideration of intestinal retransplantation. Immunological aspects remain challenging in the decision making and for short- and long-term outcomes.
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Affiliation(s)
- Burcin Ekser
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chandrashekhar A Kubal
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jonathan A Fridell
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Raveh Y, Rodriguez Y, Pretto E, Souki F, Shatz V, Ashrafi B, Manmohansigh V, Demos M, Livingstone J, Nasrallah G, Andrews D, Beduschi T, Vianna R, Nicolau-Raducu R. Thrombotic and hemorrhagic complications during visceral transplantation: risk factors, and association with intraoperative disseminated intravascular coagulation-like thromboelastographic qualities: a single-center retrospective study. Transpl Int 2018; 31:1125-1134. [DOI: 10.1111/tri.13281] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/09/2018] [Accepted: 05/15/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Yehuda Raveh
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Yiliam Rodriguez
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Ernesto Pretto
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Fouad Souki
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Vadim Shatz
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Behrouz Ashrafi
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Vinaya Manmohansigh
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Michael Demos
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Joshua Livingstone
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Georges Nasrallah
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - David Andrews
- Pathology Department; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Thiago Beduschi
- Miami Transplant Institute; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Rodrigo Vianna
- Miami Transplant Institute; Jackson Memorial Hospital; University of Miami; Miami FL USA
| | - Ramona Nicolau-Raducu
- Department of Anesthesia; Jackson Memorial Hospital; University of Miami; Miami FL USA
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Abstract
Adult intestinal transplantation differs significantly from pediatric intestinal transplantation. While indications have remained largely consistent since 2000, indications for adults have expanded over the last two decades to include motility disorders and desmoid tumors. Graft type in adult recipients depends on the distinct anatomic characteristics of the adult recipient. Colonic inclusion, while initially speculated to portend unfavorable outcomes due to complex host-bacterial interactions has increased over the past two decades with superior graft survival and improved patient quality of life. Overall, outcomes have steadily improved. For adult intestinal transplant candidates, intestinal transplantation remains a mainstay therapy for complicated intestinal failure and is a promising option for other life threatening and debilitating conditions.
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45
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Posttransplant complications in adult recipients of intestine grafts without bowel decontamination. J Surg Res 2018; 225:125-130. [DOI: 10.1016/j.jss.2018.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/06/2017] [Accepted: 01/05/2018] [Indexed: 11/23/2022]
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Clouse JW, Kubal CA, Fridell JA, Mangus RS. Complications in pediatric intestine transplantation in the absence of peri-operative donor or recipient bowel decontamination. Pediatr Transplant 2018; 22:e13164. [PMID: 29498160 DOI: 10.1111/petr.13164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2018] [Indexed: 12/20/2022]
Abstract
This study reports the clinical complication and infection rates of an active pediatric IT program that has never utilized bowel decontamination in either the donor or the recipient. All patients undergoing IT from 2003 to 2015 at a single pediatric IT center were reviewed. Post-transplant surgical, infectious, and immunosuppressive complications are reported. There were 52 patients who underwent IT during the study period. Among these patients, 4% developed a postoperative abscess, one developed an enteric fistula (2%), and one had an enteric or anastomotic leak (2%). The rate of any bacterial infection was 90% in the first year, with a wound infection rate of 23%. Any fungal infection occurred in 25% of patients. Any viral infection occurred in 75% of patients. Gastrointestinal viruses were diagnosed in 52% of patients, and cytomegalovirus infections occurred in 17%. Rejection rates were 39% at any time post-transplant (isolated 44% and 35% for multivisceral patients). At this center in which no bowel decontamination was used, rates of surgical complications, infections, and rejection were similar to those reported by other centers. These findings suggest bowel decontamination may provide no significant benefit in this population of high-risk transplant patients.
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Affiliation(s)
- Jared W Clouse
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chandrashekhar A Kubal
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jonathan A Fridell
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard S Mangus
- Department of Surgery, Transplant Division, Indiana University School of Medicine, Indianapolis, IN, USA
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47
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Grezzana-Filho TJM, Chedid MF, Chedid AD, Bassani-Filho EL, Pereira PF, Leipnitz I, Backes AN, Kruel CRP. How to do liver transplantation using renoportal bypass. ANZ J Surg 2018; 88:236-237. [PMID: 29216680 DOI: 10.1111/ans.14299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Tomaz J M Grezzana-Filho
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Marcio F Chedid
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Aljamir D Chedid
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Ernidio L Bassani-Filho
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Pedro F Pereira
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Ian Leipnitz
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Ariane N Backes
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Cleber R P Kruel
- Liver and Pancreas Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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48
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Yu YD, Kim DS, Han JH, Yoon YI. Successful Treatment of a Patient With Diffuse Portosplenomesenteric Thrombosis Using a Pericholedochal Varix for Portal Flow Reconstruction During Deceased Donor Liver Transplantation: A Case Report. Transplant Proc 2018; 49:1202-1206. [PMID: 28583558 DOI: 10.1016/j.transproceed.2017.03.066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Portal vein thrombosis remains a challenging issue in liver transplantation. When thrombectomy is not feasible due to diffuse portosplenomesenteric thrombosis, other modalities are adapted such as the use of a jump graft or portal tributaries or even multivisceral transplantation. For patients with diffuse thrombosis of the splanchnic venous system, a large pericholedochal varix can be a useful vessel for providing splanchnic blood flow to the graft and for relieving portal hypertension. We report our experience of successfully treating a patient with diffuse portosplenomesenteric thrombosis using a pericholedochal varix for portal flow reconstruction during deceased donor liver transplantation and eventually preventing unnecessary multivisceral transplantation. A 56-year-old man diagnosed with liver cirrhosis due to hepatitis B underwent deceased donor liver transplantation due to refractory ascites. Preoperative imaging revealed diffuse portosplenomesenteric thrombosis with large amount of ascites. During the operation, dissection of the main portal vein was not possible due to the development of multiple large pericholedochal varices and cavernous change of the main portal vein. After outflow reconstruction, portal inflow was restored by anastomosing the graft portal vein to a large pericholedochal varix. Postoperatively, although abdominal computed tomography scan showed stenosis of portal vein anastomosis site, liver function tests improved, and Doppler sonogram revealed no flow disturbance. During follow-up, the patient repeatedly developed hydrothorax and ascites. In addition, stenosis of the portal vein anastomosis and thrombosis of the portomesenteric system still remained. The patient underwent transhepatic portal vein stent insertion. After portal vein stent insertion, hydrothorax and ascites improved and the extent of thrombosis of the portomesenteric system decreased without anticoagulation therapy. In conclusion, enlarged pericholedochal varix in patients with totally obliterated splanchnic veins can be a source of useful inflow to restore portal flow and decrease the extent of thrombosis, thereby preventing unnecessary multivisceral transplantation.
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Affiliation(s)
- Y-D Yu
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Korea University Medical Center, Korea University Medical College, Seoul, Korea
| | - D-S Kim
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Korea University Medical Center, Korea University Medical College, Seoul, Korea.
| | - J-H Han
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Korea University Medical Center, Korea University Medical College, Seoul, Korea
| | - Y-I Yoon
- Department of Surgery, Division of HBP Surgery and Liver Transplantation, Korea University Medical Center, Korea University Medical College, Seoul, Korea
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49
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Amin I, Rutter C, Barlow A, Russell NK, Bradley JA, Jackson A, Butler AJ. Simultaneous Intestinal and Kidney Transplantation in Adults. J INVEST SURG 2018; 32:283-289. [DOI: 10.1080/08941939.2017.1409849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Irum Amin
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Charlotte Rutter
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Adam Barlow
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Neil K. Russell
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - J. Andrew Bradley
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Andrew Jackson
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Andrew J. Butler
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
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50
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He XS, Fu SJ, Zhao Q, Zhu XF, Wang DP, Han M, Ju WQ, Ma Y, Jiao XY, Yuan XP, Hu AB, Guo ZY. A simplified multivisceral transplantation procedure for patients with combined end-stage liver disease and type 2 diabetes mellitus. Liver Transpl 2017; 23:1161-1170. [PMID: 28422396 DOI: 10.1002/lt.24774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 03/25/2017] [Accepted: 04/06/2017] [Indexed: 01/13/2023]
Abstract
In liver transplant patients with type 2 diabetes mellitus (DM), the disease worsens after transplantation because of longterm use of diabetogenic immunosuppressive drugs, making management of those patients a great challenge. The objective of our study was to evaluate the safety and efficacy of a simplified multivisceral transplantation (SMT) procedure for the treatment of patients with end-stage liver disease and concurrent type 2 DM. Forty-four patients who had pretransplant type 2 DM were included. A total of 23 patients received SMT, and 21 patients received orthotopic liver transplantation (OLT). Patient and graft survivals, complications, diabetic control, and quality of life (QOL) were retrospectively analyzed in both groups. The 1-, 3-, and 5-year cumulative patient and graft survival rates were 91.5%, 75.4%, and 75.4% in the SMT group and were 94.4%, 64.4%, and 64.4% in the OLT group, respectively (P = 0.70). Interestingly, 95.7% (22/23) of patients achieved complete remission from DM after SMT compared with 16.7% (3/18) of patients after OLT. The occurrence of biliary complication was significantly higher in the OLT group than that in the SMT group (23.8% versus 0.0%; P = 0.01). Moreover, better QOL was observed in the SMT group than that in the OLT group. In conclusion, the SMT procedure we described here is a safe and viable option for patients with end-stage live disease and concurrent type 2 DM. This SMT procedure offers excellent transplant outcomes and QOL. Liver Transplantation 23 1161-1170 2017 AASLD.
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Affiliation(s)
- Xiao-Shun He
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
| | - Shun-Jun Fu
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
| | - Qiang Zhao
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
| | - Xiao-Feng Zhu
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
| | - Dong-Ping Wang
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
| | - Ming Han
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
| | - Wei-Qiang Ju
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
| | - Yi Ma
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
| | - Xing-Yuan Jiao
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
| | - Xiao-Peng Yuan
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
| | - An-Bin Hu
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
| | - Zhi-Yong Guo
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.,Organ Transplantation, Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, People's Republic of China
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