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Basso CD, Meniconi RL, Usai S, Guglielmo N, Colasanti M, Ferretti S, Sandri GBL, Ettorre GM. Portal vein arterialization following a radical left extended hepatectomy for Klatskin tumor: A case report. Ann Hepatobiliary Pancreat Surg 2021; 25:426-430. [PMID: 34402447 PMCID: PMC8382860 DOI: 10.14701/ahbps.2021.25.3.426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 12/01/2022] Open
Abstract
Portal vein arterialization (PVA) has been attracting attention for its role as a salvage inflow technique in various clinical applications. Initially performed in shunt surgery for portal hypertension, with the aim of preventing a decreased hepatic inflow, it is largely used in case of hepatic artery thrombosis in the transplantation domain or in the enlarged radical operations in case of hilar cancer invading the hepatic artery. A 62-year-old man underwent a left extended hepatectomy with hepatic bile duct resection and right Roux-en-Y hepaticojejunostomy for hilar cholangiocarcinoma. Computed tomography scan on postoperative day (POD) 5 revealed right hepatic artery pseudo-aneurysm, which was confirmed by an angiography. Stent placement was infeasible. Coiling of the pseudoaneurysm was associated with a risk of complete occlusion inducing critical liver failure. Since his general conditions were deteriorated, the patient underwent an emergency laparotomy. Hepatic artery reconstruction was impossible. Thus, a PVA was performed by anastomosing the ileocecal artery and vein. The intraoperative ultrasound showed satisfactory patency of the PVA with good portal flow in the absence of arterial flow. Doppler ultrasound on POD 15 showed that the cross-sectional area and blood flow of the portal vein were increased. The patient was discharged on POD 54 in good general condition. Hepatic artery disruption represents potentially lethal complications of hepatic, biliary, and pancreatic surgery. PVA may be a feasible therapeutic strategy to guarantee arterial inflow to the remnant liver. Although PVA is a salvage surgical procedure, increased portal flow should be controlled to avoid portal hypertension and liver fibrosis.
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Affiliation(s)
- Celeste Del Basso
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Roberto Luca Meniconi
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Sofia Usai
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Nicola Guglielmo
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Marco Colasanti
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Stefano Ferretti
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | | | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
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Lerut JP, Lai Q, de Ville de Goyet J. Cavoportal Hemitransposition in Liver Transplantation: Toward a More Safe and Efficient Technique. Liver Transpl 2020; 26:92-99. [PMID: 31509649 DOI: 10.1002/lt.25635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
Extended splanchnic venous thrombosis represents a challenge for the liver transplantation (LT) surgeon. In the absence of large venous tributaries, the cavoportal hemitransposition (CPHTr) and the combined liver-intestinal or multivisceral transplantation are the only technical solutions. Because of the reported high morbidity and mortality rates due to infrequent use and a lack of standardization, the former technique has been almost abandoned by the transplant community. A newly designed technique of CPHTr is presented that is based on the combination of an inferior vena cava (IVC)-sparing hepatectomy and large laterolateral cavocaval and end-to-side cavoportal anastomoses separated only by a double vascular stapler line. This technique allows the splanchnic blood to be completely diverted toward the allograft and to eliminate low-flow IVC areas, which possibly lead to complications. The modified CPHTr technique proposed here offers a valuable alternative to much more complex and invasive intestinal transplantation procedures.
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Affiliation(s)
- Jan P Lerut
- Institute for Experimental and Clinical Research, Université Catholique de Louvain, Brussels, Belgium
| | - Quirino Lai
- Liver Transplant Program, Sapienza University of Rome, Rome, Italy
| | - Jean de Ville de Goyet
- University Pittsburgh Medical Center-Italy, Istituto Mediterraneo for Trapianto e Terapie ad Alta Specializzazione, Istituto di Ricovero e Cura a Carattere Scientifico, Palermo, Italy
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Lapisatepun W, Chotirosniramit A, Sandhu T, Udomsin K, Ko-Iam W, Chanthima P, Lapisatepun W, Boonsri S, Lorsomradee S, Kaewpoowat Q, Junrungsee S. Price to pay; Portal vein arterialization for hepatic artery thrombosis after living donor liver transplantation; A case report. Int J Surg Case Rep 2018; 47:71-74. [PMID: 29751198 PMCID: PMC5994732 DOI: 10.1016/j.ijscr.2018.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/29/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Hepatic artery thrombosis (HAT) is one of the most serious complications of liver transplantation that can potentially lead to loss of the allograft. Retransplantation is the only option when revascularization can't be performed but the donor may be not available in the short period of time. We report the technique of using portal vein arterialization (PVA) for bridging before retransplantation. There are few reports in living donor setting. CASE DESCRIPTION The recipient of the liver was a 59 year old male who received an extended right lobe graft from his son. Post operative day 41, HAT was diagnosed from angiogram and liver function got rapidly worse. We decided to re-anastomose the hepatic artery but this was not possible due to a thrombosis in the distal right hepatic artery. So PVA by anastomosis of the common hepatic artery to splenic vein was performed. During the early postoperative period liver function gradually improved. Unfortunately, he died from massive GI hemorrhage one month later. DISCUSSION PVA has previously been reported as being useful when revascularization was not successful. The surgical technique is not complicated and can be performed in sick patient. Liver graft may be salvaged with oxygenated portal flow and recover afterwards. However, portal hypertension after PVA seem to be an inevitable complication. CONCLUSIONS PVA may be a bridging treatment for retransplantation in patients whom hepatic artery reconstruction is impossible after HAT. Regards to the high morbidity after procedure, retransplantation should be performed as definite treatment as soon as possible.
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Affiliation(s)
- Worakitti Lapisatepun
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
| | - Anon Chotirosniramit
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
| | - Trichak Sandhu
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
| | - Kanya Udomsin
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
| | - Wasana Ko-Iam
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
| | - Phuriphong Chanthima
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Thailand
| | | | - Settapong Boonsri
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Thailand
| | | | - Quanhathai Kaewpoowat
- Division of Infectious and Tropical Medicine, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Thailand
| | - Sunhawit Junrungsee
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand.
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Qiao JL, Sun J, Li J, Zhang JJ, Meng XK. Liver dual arterial blood supply maintains liver regeneration: Analysis of signaling pathways in rats. Mol Med Rep 2017; 17:979-987. [PMID: 29115531 PMCID: PMC5780179 DOI: 10.3892/mmr.2017.7961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 10/18/2017] [Indexed: 11/06/2022] Open
Abstract
Liver dual arterial blood supply (LDABS) could increase blood supply to the liver and maintain normal liver regeneration in patients with compromised portal vein. The current study attempted to examine the underlying molecular mechanisms. Male Sprague-Dawley rats randomly received partial hepatectomy (PH) alone or PH followed by LDABS. Liver regeneration was assessed by histological examination, liver function and liver regeneration rate (LRR). Whole-genome oligo microarray analysis was used to compare gene expression profile between rats receiving PH and rats receiving PH plus LDABS. Key genes identification was validated using a MAPK signaling polymerase chain reaction (PCR) array. The extent of liver regeneration in rats receiving PH plus LDABS was comparable to that in rats receiving PH alone. The differentially expressed genes were enriched in 12 signaling pathways in two groups. MAPK signaling pathway, NF-kappa B signaling pathway, and Toll-like receptor signaling pathway were involved in LDABS-mediated liver regeneration, with Retinoblastoma 1 (Rb1), Cyclin D1, Cyclin-dependent kinase 4, Mitogen-activated protein kinase 10 (Mapk10) and CAMP responsive element binding protein 1 genes in the initiation phase, Kirsten rat sarcoma viral oncogene homolog (Kras), tumor protein 53, MYC proto-oncogene, BHLH transcription factor, Cyclin E1 and Heat shock protein family B (small) member 1 genes in the proliferation phase, Kras, Rb1, Jun proto-oncogene, AP-1 transcription factor subunit, Cyclin D2 and Mapk10 genes in the termination phase were identified as key genes in LDABS-mediated liver regeneration using MAPK signaling PCR array analysis.
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Affiliation(s)
- Jian-Liang Qiao
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, P.R. China
| | - Juan Sun
- Department of Immunology, Inner Mongolia Medical University, Hohhot 010110, P.R. China
| | - Jun Li
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, P.R. China
| | - Jun-Jing Zhang
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, P.R. China
| | - Xing-Kai Meng
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, P.R. China
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Qiao J, Han C, Zhang J, Wang Z, Meng X. A new rat model of auxiliary partial heterotopic liver transplantation with liver dual arterial blood supply. Exp Ther Med 2015; 9:367-371. [PMID: 25574199 PMCID: PMC4280989 DOI: 10.3892/etm.2014.2110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 10/16/2014] [Indexed: 01/23/2023] Open
Abstract
Auxiliary partial heterotopic liver transplantation (APHLT) with portal vein arterialization is a valuable procedure to be considered in the treatment of patients with acute liver failure and metabolic liver diseases. The aim of this study was to develop a new rat model of APHLT with liver dual arterial blood supply (LDABS). A total of 20 rats were used. The donor liver was resected, and the celiac trunk was reserved. Left and medial hepatic lobes accounting for 70% of the liver mass were removed en bloc and the suprahepatic caval vein was ligated simultaneously. Thus, 30% of the donor liver was obtained as the graft. Sleeve anastomosis of the graft portal vein and splenic artery were performed after narrowing the portal vein lumen through suturing. The right kidney of the recipient was removed, and sleeve anastomosis was performed between the celiac trunk of the graft and the right renal artery of the recipient. In addition, end-to-end anastomosis was performed between the infrahepatic caval vein of the graft and the right renal vein of the recipient. Following the reperfusion of the graft, the blood flow of the arterialized portal vein was controlled within the physiological range through suturing and narrowing under monitoring with an ultrasonic flowmeter. The bile duct of the graft was implanted into the duodenum of the recipient through an internal stent catheter. A 70% section of the native liver (left and medial hepatic lobes) was resected using bloodless hepatectomy. The mean operative duration was 154.5±16.4 min, and the warm and cold ischemia times of the graft were 8.1±1.1 min and 64.5±6.6 min, respectively. The blood flow of the arterialized portal vein to the graft was 1.8±0.3 ml/min/g liver weight. The success rate of model establishment (waking with post-surgical survival of >24 h) was 70% (7/10). Following successful model establishment, all rats survived 7 days post-surgery (100%; 7/7). The graft was found to be soft in texture and bright red in color following exploratory laparotomy. In conclusion, a new rat model of APHLT with LDABS without stent for vascular reconstruction was developed. This is a feasible and reliable rat model for liver transplantation study.
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Affiliation(s)
- Jianliang Qiao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China ; Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
| | - Chunlei Han
- Turku PET Centre, Turku University Hospital and University of Turku, Turku 20521, Finland
| | - Junjing Zhang
- Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
| | - Zhiyong Wang
- Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
| | - Xingkai Meng
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China ; Department of General Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region 010050, P.R. China
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Portal blood arterialization with an extracorporeal device to treat toxic acute hepatic failure in a swine model. Int J Artif Organs 2014; 37:847-53. [PMID: 25501739 DOI: 10.5301/ijao.5000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE This study aimed to determine whether a controlled portal blood arterialization by a liver extracorporeal device (L.E.O2 NARDO) is effective in treating acute hepatic failure (AHF) induced through CCl4 administration in a swine model. METHODS 20 swine with AHF induced by intraperitoneal injection of carbon tetrachloride (CCl4) in oil solution, were randomly divided into two groups: animals receiving L.E.O2 NARDO treatment 48 h after the intoxication (study group); animals sham operated 48 h after the intoxication (control group). Blood was withdrawn from the iliac artery and reversed in the portal venous system by an interposed extracorporeal device. Each treatment lasted 6 h. The survival was assessed at 5 days after L.E.O2 NARDO treatment or sham operation. In both groups blood samples were collected for biochemical analysis at different time points and liver biopsies were collected 48 h after intoxication and at sacrifice. RESULTS We observed decreased transaminases levels and a more rapid INR recovery in the study group, as compared to the control group. Eight animals of the study group vs. two animals of the control group survived at five days after surgery with a statistically significant difference (p<0.05). Liver biopsies performed at sacrifice showed a reduction of the damaged hepatic areas in the study group as compared to the control group. CONCLUSIONS Arterial blood supply in the portal system through the L.E.O2 NARDO device is easily applicable, efficacious, and safe in a swine model of AHF induced by CCl4 intoxication.
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