1
|
Barron JO, Radhakrishnan K, Coppa C, Goldman D, Hupertz V, Leonis M, Eghtesad B, Hashimoto K. Ten-year follow-up of cavoportal hemitransposition in pediatric liver transplantation for complete portomesenteric venous thrombosis: A case report and literature review. Pediatr Transplant 2024; 28:e14738. [PMID: 38436520 DOI: 10.1111/petr.14738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/13/2023] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Portal vein thrombosis is a potentially devastating complication following pediatric liver transplantation. In rare instances of complete portomesenteric thrombosis, cavoportal hemitransposition may provide graft inflow. Here we describe long-term results following a case of pediatric cavoportal hemitransposition during liver transplantation and review the current pediatric literature. METHODS A 9-month-old female with a history of biliary atresia and failed Kasai portoenterostomy underwent living donor liver transplantation, which was complicated by portomesenteric venous thrombosis. The patient underwent retransplantation with cavoportal hemitransposition on postoperative day 12. OUTCOME The patient recovered without further complication, and 10 years later, she continues to do well, with normal graft function and no clinical sequelae of portal hypertension. CT scan with 3-D vascular reconstruction demonstrated recanalization of the splanchnic system, with systemic drainage to the inferior vena cava via an inferior mesenteric vein shunt. The cavoportal anastomosis remains patent with hepatopetal flow. Of the 12 previously reported cases of pediatric cavoportal hemitransposition as portal inflow in liver transplantation, this is the longest-known follow-up with a viable allograft. Notably, sequelae of portal hypertension were also rare in the 12 previously reported cases, with no cases of long-term renal dysfunction, lower extremity edema, or ascites. CONCLUSIONS Long-term survival beyond 10 years with normal graft function is feasible following pediatric cavoportal hemitransposition. Complications related to portal hypertension were generally short-lived, likely due to the development of robust collateral circulation. Additional reports of long-term outcomes are necessary to facilitate informed decision making when considering pediatric cavoportal hemitransposition for liver graft inflow.
Collapse
Affiliation(s)
- John O Barron
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kadakkal Radhakrishnan
- Department of Pediatric Hepatology and Gastroenterology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christopher Coppa
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deborah Goldman
- Department of Pediatric Hepatology and Gastroenterology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vera Hupertz
- Department of Pediatric Hepatology and Gastroenterology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mike Leonis
- Department of Pediatric Hepatology and Gastroenterology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
2
|
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: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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.
| |
Collapse
|