Immunohistochemical evaluation for outflow reconstruction using opened round ligament in living donor right posterior sector graft liver transplantation: A case report

Feasibility of modified endarterectomized aortic allograft for middle hepatic vein reconstruction in living donor liver transplantation: A retrospective cohort study

BACKGROUND

Cryopreserved allografts and artificial vascular grafts were introduced to meet the increasing demand for adequate vascular substitutes for middle hepatic vein (MHV) reconstruction during living donor liver transplantation (LDLT). This study evaluated patency outcomes after engraftment of a modified endarterectomized aortic allograft (MEAA) without any additional patches.

METHODS

This retrospective double-arm study was conducted in single tertiary referral center between January 2015 and July 2018. Of 1,047 adult patients who underwent single-graft LDLT with a modified right lobe (MRL), 111 patients who received grafts with MHV reconstruction using MEAA were selected. The control group comprised 434 patients who underwent MHV reconstruction using iliac vein allografts. The main outcome measure was the short-term patency of the MEAA. The secondary outcome was the incidence of graft-associated complications.

RESULTS

Clinically significant MHV stenoses requiring stenting occurred in 3 patients (2.7%) in the MEAA group and in 17 patients (3.9%) in the iliac vein group (P = 0.778). Three-month and one-year patency rates on Doppler ultrasonography and computed tomography were 88.5% and 54.0%, respectively, in the MEAA group and 84.0% and 42.2%, respectively, in the iliac vein group, indicating the superior patency outcomes with MEAA (P = 0.017).

CONCLUSIONS

MHV reconstruction using MEAA during LDLT of a MRL graft is technically simple, achieves clinical outcomes comparable to iliac vein grafts, and is effective in expanding the allograft vessel pool for LDLT.

Novel Approach via the Round Ligament in Portal Vein Embolization

BACKGROUND

The objective of this study was to describe the detailed technique and clinical outcomes of portal vein embolization via the round ligament (RL-PVE) prior to major hepatectomy.

METHODS

Between January 2010 and March 2020, a total of 50 portal vein embolization (PVE) procedures were performed in 50 patients. Of them, seven patients who underwent RL-PVE were enrolled in this study. Percutaneous transhepatic portal vein embolization (PTPE) was not indicated due to the following reasons: bile duct dilation (n = 4), difficulty in visualizing the portal vein on ultrasonography because of severe fatty liver (n = 1), large tumor size (n = 1), and combined surgery with staging laparoscopy (n = 1). The following were reasons for avoiding trans-ileocecal PVE: past laparotomy (n = 5), difficulty in accessing the portal vein due to a large tumor (n = 1), and purpose of preventing small intestinal adhesions before hepatopancreatoduodenectomy (n = 1). The percentage of functional hepatic remnant rates was calculated before and after RL-PVE.

RESULTS

Technical success was achieved in all cases. Five patients underwent embolization of the right portal vein, while two underwent embolization of the left portal vein. The median operative time and blood loss during RL-PVE were 181 min and 33 g, respectively. Morbidity and mortality related to RL-PVE were not observed. The median functional hepatic remnant rate before and after PVE was 55.6% and 63.2%, respectively. Liver functions including Child-Pugh classification were equivalent before and after RL-PVE.

CONCLUSIONS

The RL-PVE technique may be useful in elective cases for which it is difficult to safely perform PTPE or trans-ileocecal approaches.

Use of the ligamentum teres hepatis for outflow reconstruction during ex vivo liver resection and autotransplantation in patients with hepatic alveolar echinococcosis: A case series of 24 patients

BACKGROUND

Patients with extensive hepatic alveolar echinococcosis might require ex vivo liver resection and autotransplantation to remove the lesion. Patients with extensive vascular invasion will need reconstruction, but the selection of the proper graft is complicated. This study aimed to investigate the effectiveness and adverse events of using the ligamentum teres hepatis as a vascular replacement graft in ex vivo liver resection and autotransplantation.

METHODS

This was a retrospective case series of patients with hepatic alveolar echinococcosis who underwent ex vivo liver resection and autotransplantation between August 2010 and October 2018 and in whom the ligamentum teres hepatis was used to repair the remnant liver. The operative outcomes, recurrence, and survival were examined.

RESULTS

Twenty-four patients were included (10 men, 14 women). The anhepatic period was 290 to 672 minutes (median of 450 minutes). The ratio of the remnant liver volume to the standard liver volume was 0.43 to 0.97 (median of 0.71). The blood loss was 1,000 (500-5,000) mL. The postoperative hospital stay was 23 (1-85) days. Of the 24 patients, 3 died after the operation, but those deaths were unrelated to liver vascular complications.

CONCLUSION

The ligamentum teres hepatis could be used as a vascular replacement graft in ex vivo liver resection and autotransplantation. It has the advantages of convenient specimen extraction, no donor site injury, and no immunological rejection, which has promising clinical application prospects.

Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy

BACKGROUND AND PURPOSE

Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy.

METHODS

Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed.

RESULTS

The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy.

CONCLUSIONS

Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.