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Microscope-assisted Hepatic Artery Reconstruction in Adult Living Donor Liver Transplantation - A Review of 325 Consecutive Cases in A Single Center
Abstract
Background:
Despite the technical and medical improvements in the recent years, hepatic artery thrombosis (HAT) remains a devastating complication after living donor liver transplantation (LDLT). We described our surgical techniques and monitoring protocols for hepatic artery reconstruction. We reported one of the lowest incidence rates of HAT in the literature.
Methods:
Between 2008 and 2015, a total of 325 LDLTs performed at our institute were retrospectively analyzed. Under microscope assistance, all hepatic artery anastomosis were performed in a risk-free and back-wall first manner. We collected donors and recipients' demographics, operative procedures and outcome.
Results:
A total of 325 adult LDLTs were enrolled in the study. Of these, 297(91.4%) were right liver graft. The mean diameter of the hepatic arteries of the graft was 1.9±0.3mm. A single HA anastomosis was performed in 310 patients (95.4%). The 1-, 3-, and 5-year overall patient survival rates were 84.8%, 76.8% and 75.2% respectively. Only one (0.3%) episode of HAT was encountered in our series. The patient was treated successfully with non-surgical management.
Conclusion:
Our study showed that the occurrence of HAT is evitable. Identifying risk factors associated with HAT, meticulous surgical techniques and carefully routine flow monitoring are mandatory to avoid disastrous complications. This article is protected by copyright. All rights reserved.
... The liver may be retracted superiorly using a Thompson retractor to expose the vessels or a moist penny towel placed in the subdiaphramatic space to bring the liver forward, especially when the vessel stumps are short. A moist sponge may be placed deep to the vessels to elevate the plane of anastomosis and prevent fluid from interfering with field (26). Suction tube hooked to a small (5 French) feeding tube or cannulation tube can be placed beneath gauze or cottonoid to keep the field dry and optimize visualization. ...
... Before the anastomosis, it is important to check for risk factors that can cause hepatic artery thrombosis. These include soft thrombus in the artery (these must be removed), intimal or medial wall dissection (vessel should be cut back to an area that is healthy), or intimal flaps protruding into the lumen (26). Intimal flaps may cause turbulence and should be trimmed off circumferentially. ...
... The site of hepatic artery anastomosis is usually deep within the abdominal cavity, which results in limited surgical motion and field of vision (57,58). This limited space may also cause kinking of the vessels post anastomosis and manipulation of the bile ducts may push the vessels into an undesirable orientation (26). To overcome this challenge, as mentioned previously, the role of the second assistant to manually retract the surrounding bowel loops and donor liver cannot be understated. ...
Background and Objective
Liver transplantation is a life-saving procedure, but also associated with complications. Hepatic artery thrombosis is one of the most devastating complications, especially for living donor liver transplantation. The application of microsurgical techniques for hepatic artery reconstruction has greatly reduced the risk of hepatic artery thrombosis. In this narrative review, we discuss the technical considerations and challenges faced in microsurgical reconstruction of hepatic artery in liver transplantation.
Methods
PubMed, Web of Science, and Google Scholar were searched for keywords relating to “liver transplantation”, “microsurgery”, “living donor liver transplantation”, “deceased donor liver transplantation”, “hepatic artery”, “hepatic artery thrombosis”, “hepatic artery reconstruction” and “microsurgical anastomosis”. Relevant articles pertaining to the technical considerations and challenges of microsurgery in liver transplantation were included.
Key Content and Findings
The conditions of liver transplantation pose unique challenges to the microsurgeon. Nonetheless, there are described strategies that can overcome these conditions, as well as technical details that may improve the outcomes of hepatic artery reconstruction. These strategies start from proper positioning of the patient, conscientious selection of donor and recipient hepatic vessels, and minimizing movements during critical microsurgical anastomosis. Technical details include techniques to overcome vessel delamination, size mismatch, poor quality vessels, and short vessel stump. This review also explores the outcomes of microsurgical hepatic arterial reconstruction.
Conclusions
There are various strategies to mitigate the challenges of microsurgery in liver transplant. Microsurgery improves the outcome of liver transplantation. Microsurgeons will continue to be a priceless resource that all liver transplant teams should have.
... Several studies have focused on HAT, identifying factors that mitigate its complications. These include early HAT detection using twice-daily Doppler, increased surgical experience, and refinements in surgical technique [10,11]. Notably, one study found a decreased incidence of HAT with microsurgical techniques, use of living donors, and involving plastic surgeons trained in microsurgery for hepatic artery anastomosis [12]. ...
... In hepatic artery anastomosis, microscopes aid not only in vessel anastomosis but also in identifying other HAT risk factors, like uneven intima edges or thrombi in arterial stumps [11]. However, even the highest magnification with loupe-assisted anastomoses (4.5x) falls short compared to the 9x lens on a microscope. ...
Introduction: Before advancements in liver transplantation, conditions such as acute liver failure, decompensated liver cirrhosis, and hepatocellular carcinoma were associated with poor prognosis. Orthotopic liver transplantation has since emerged as a curative treatment. Despite its benefits, liver transplantation can lead to complications, including hepatic artery thrombosis (HAT), which is especially significant in pediatric patients. This study evaluates the utility of microsurgical anastomosis by plastic surgeons in reducing postoperative HAT compared to standard loupe-assisted anastomosis performed by transplant surgeons.
Methods: This retrospective chart review included pediatric patients who underwent orthotopic liver transplantation at a single institution between September 2015 and September 2023. Patients were divided into two groups: one receiving standard loupe-assisted anastomosis by transplant surgeons (n = 28) and the other receiving microsurgical anastomosis by plastic surgeons (n = 22). The primary outcomes measured were the rates of HAT. Secondary outcomes included graft survival, patient survival, postoperative hospital stay, resistive indices, bleeding, biliary complications, venous complications, transplant rejection, and reoperation rates.
Results: In 50 pediatric patients who underwent orthotopic liver transplantation, we compared outcomes between standard anastomosis (n = 28) and microscope-assisted anastomosis (n = 22). Demographic characteristics were similar between the groups. Hemorrhage occurred significantly more frequently in the standard anastomosis group (35.7%) compared to the microscope-assisted group (9.1%), with a p-value of 0.045. Other complications, including HAT (28.6% vs. 13.6%, p = 0.306), biliary leak (14.3% vs. 27.3%, p = 0.302), and organ rejection (21.4% vs. 13.6%, p = 0.713), did not differ significantly between the groups. Additionally, survival rates were comparable, with 71% in the standard group and 86% in the microscope group (p = 0.306). These findings suggest that while microscope-assisted anastomosis may reduce the risk of hemorrhage, other outcomes remain similar between the techniques.
Conclusion: Our findings suggest that microsurgical anastomosis techniques performed by plastic surgeons are non-inferior to standard loupe-assisted techniques in pediatric liver transplantation and may decrease the rate of postoperative hemorrhage. Microsurgical anastomosis is a viable alternative to standard loupe-assisted techniques in pediatric hepatic artery transplants. Further research with larger sample sizes is warranted to confirm these findings and optimize surgical techniques.
... (Fig. 2) Generally, the necessity for the reconstruction of MHV tributaries, mainly the drainage of segments 5 (V5) and 8 (V8), could also be determined based on numerous proposed algorithms for right liver graft LT. [30][31][32][33] With growing experience in LT as well as LDLT, the implementation of microscopic reconstruction for small hepatic arteries and bile ducts may also be accomplished without much difficulty in SPLT using hemi-liver grafts from deceased donors. [34][35][36] ...
Liver transplantation has become a routine operation in many transplantation centers worldwide. However, liver graft availability fails to meet patient demands. Split liver transplantation (SPLT), which divides a deceased donor liver into 2 partial liver grafts, is a promising strategy for increasing graft availability for transplantation and ameliorating organ shortage to a certain degree. However, the transplantation community has not yet reached a consensus on SPLT because of the variable results. Specifically, SPLT for 2 adult recipients using full right/left hemi-liver grafts is clinically more challenging in terms of surgical technique and potential postoperative complications. Therefore, this review summarizes the current status of SPLT, focusing on the transplantation of adult recipients. Furthermore, the initiation of the SPLT program, donor allocation, surgical aspects, recipient outcomes, and obstacles to developing this procedure will be thoroughly discussed. This information might help provide an optimal strategy for implementing SPLT for 2 adult recipients among current transplantation societies. Meanwhile, potential obstacles to SPLT might be overcome in the near future with growing knowledge, experience, and refinement of surgical techniques. Ultimately, the widespread diffusion of SPLT may increase graft availability and mitigate organ donation shortages.
Hepatic Arterial Anastomosis is the most important procedure in living donor liver transplantation. For optimal stump function, it is critical to ensure meticulous and atraumatic dissection of hepatic hilum in both the donor and recipient operations. A partial graft artery is small and thin, especially with multiple arteries. Therefore, a precise anastomotic technique is required for safe anastomosis with a surgical microscope or loupes. In the recipient hilar dissection, each of the arterial stumps is identified up to at least the second branches for size matching with the donor arterial stumps. Interrupted or continuous anastomotic techniques are commonly used with several modifications. For stumps that are too short, the backwall first technique is useful, and this was done here without stump rotation. It is preferable to subject all graft arterial stumps to anastomosis if possible. Following anastomosis, doppler ultrasonography is performed to evaluate the patency. In the case of arterial thrombosis, early re-anastomosis with different health inflow is essential for graft saving.
Background
Failure to achieve a good arterial inflow to the graft in living donor liver transplantation (LDLT) has disastrous consequences to the graft and patient survival. Standard microvascular techniques of hepatic artery (HA) anastomosis used in deceased donor liver transplantation are not applicable in LDLT. We present the results of our unique Backwall-first technique of HA anastomosis in both adult and pediatric LDLT.Patients and methodsRetrospective review of all consecutive patients who underwent LDLT from January 2010 to December 2020 was performed from our prospective database. Data with regard to early postoperative (90-day) hepatic arterial complications were analyzed.ResultsA total of 1276 LDLTs (876 adults, 400 children) were performed during the study period. In the 90-day postoperative period, HA anastomotic complications [thrombosis in 11 (0.9%); pseudoaneurysm in 3 (0.2%)] were observed in 14 recipients (1.1%) including 8 adults (0.9%) and 6 children (1.5%). Eight of these 14 recipients (0.6%) including 4 adults (0.5%) and 4 children (1%) had standard HA reconstruction. The remaining six (0.5%) including 4 adults and 2 children had complex arterial reconstruction with interposition graft and/or alternative arterial inflow.Conclusion
The Backwall-first technique of HA reconstruction described in this study achieved a very low HA complication rate in LDLT.
Background
Hepatic artery reconstruction is an essential part of liver transplantation. This difficult stage of the operation is even more demanding in living donor liver transplantation than in deceased donor liver transplantation. One of the most important advances in hepatic artery reconstruction for living liver grafts was the introduction of microsurgical techniques involving an operative microscope or surgical loupe. Many surgical reconstruction techniques have been used in this field.
Purpose
In this article, first, we will talk about the hepatic artery reconstruction techniques that are frequently used in deceased donor liver transplantation, and afterward, we will talk about the hepatic artery reconstruction techniques used in living donor liver transplantation, which include the hepatic artery reconstruction technique we use and call “one stay corner suture technique”.
Conclusions
We think high-volume transplant centers should tend to develop a standardized technique for doing hepatic artery reconstruction with their teams. We think the “one stay corner suture technique” can be easily applied in centers that perform LDLT.
Background Microvascular hepatic artery reconstruction (MHAR) is associated with decreased rates of hepatic artery thrombosis (HAT) in living donor liver transplantation (LDLT). There is a paucity of literature describing the learning points and invitation of this technique at the institutional level. The objective of this study is to report our institutional experience using MHAR in adult LDLT with a focus on technique and outcomes.
Methods A retrospective review of adult patients who underwent LDLT from January 2012 to December 2020 was conducted. Patients were divided into two groups, those who underwent LDLT without MHAR and with MHAR. We analyzed cases for technical data including donor and recipient artery characteristics, anastomotic techniques, intraop events, and postop complications. A Mann–Whitney test was performed to compare outcomes between non-MHAR and MHAR patients.
Results Fifty non-MHAR and 50 MHAR patients met inclusion criteria. Median age at transplantation was 58 (interquartile range [IQR] 11.8) and 57.5 years (IQR 14.5), respectively. Median follow-up for MHAR patients was 12.8 months (IQR 11.6). The most common recipient arteries were the right hepatic artery (HA) (58%) and left HA (20%). Median size of recipient and donor arteries were 3.3 mm (IQR 0.7) and 3.1 mm (IQR 0.7), resulting in a median mismatch size of 0.3 mm (IQR 0.4). Median microanastomosis time was 44 minutes (IQR 0). HAT, graft failure, and mortality rates were higher in the non-MHAR cohort (6% vs. 0%, 8% vs. 0%, and 16% vs. 6%, respectively); however, these did not reach statistical significance.
Conclusion This study found lower rates of HAT and graft failure after implementing MHAR, though statistical significance was not achieved. Larger cohort studies are needed to further assess the potential benefit of MHAR in adult LDLT. From our experience, MHAR requires cooperation between the transplant and microsurgical teams, with technical challenges overcome with appropriate instrumentation and planning.
Microsurgery refers to the surgical coaptation of small structures (vessels, nerves, lymphatics, etc.), usually around 1 mm in diameter, performed under magnification with microinstruments and ultrafine sutures.
Background Living donor liver transplantation (LDLT) has expanded the availability of liver transplant but has been associated with early technical complications including the devastating complication of hepatic artery thrombosis (HAT), which has been reported to occur in 14% to 25% of LDLT using standard anastomotic techniques. Microvascular hepatic artery reconstruction (MHAR) has been implemented in an attempt to decrease rates of HAT. The purpose of this study was to review the available literature in LDLT, specifically related to MHAR to determine its impact on rates of posttransplant complications including HAT.
Methods A systematic review was conducted using PubMed/Medline and Web of Science. Case series and reviews describing reports of microscope-assisted hepatic artery anastomosis in adult patients were considered for meta-analysis of factors contributing to HAT.
Results In all, 462 abstracts were screened, resulting in 20 studies that were included in the meta-analysis. This analysis included 2,457 patients from eight countries. The pooled rate of HAT was 2.20% with an overall effect size of 0.00906.
Conclusion Systematic literature review suggests that MHAR during LDLT reduces vascular complications and improves outcomes posttransplant. Microvascular surgeons and transplant surgeons should collaborate when technical challenges such as small vessel size, short donor pedicle, or dissection of the recipient vessel wall are present.
The objective of this study was to evaluate the results of adult ABO-incompatible living donor liver transplantation (LDLT).
ABO-incompatible LDLT is an aggressive treatment that crosses the blood-typing barrier for saving lives from liver diseases. Although graft and patient survival have been improved recently by various treatments, the results of adult ABO-incompatible LDLT require further evaluation.
Two regimens were designed based on isoagglutinin IgG and IgM titers and the time course of immunological reactions at this institute. When isoagglutinin IgG and IgM titers were ≤64, liver transplantation was directly performed and rituximab (375 mg/m2) was administrated on postoperative day 1 (regimen I). When isoagglutinin titers were >64, rituximab (375 mg/m2) was administered preoperatively with or without plasmapheresis and boosted on postoperative day 1 (regimen II). Immunosuppression was achieved by administration of mycophenolate mofetil, tacrolimus, and steroids.
Forty-six adult ABO-incompatible and 340 ABO-compatible LDLTs were performed from 2006 to 2013. The Model for End-Stage Liver Disease scores for ABO-incompatible recipients ranged from 7 to 40, with a median of 14. The graft-to-recipient weight ratio ranged from 0.61% to 1.61% with a median of 0.91%. The 1-, 3-, and 5-year survival rates were 81.7%, 75.7%, and 71.0%, respectively, for ABO-incompatible LDLT recipients, compared to 81.0%, 75.2%, and 71.5% for ABO-C recipients (P = 0.912). The biliary complication rate was higher in ABO-incompatible LDLT recipients than in the ABO-compatible recipients (50.0% vs 29.7%, P = 0.009).
In the rituximab era, the blood type barrier can be crossed to achieve adult ABO-incompatible LDLT with survival rates comparable to those of ABO-compatible LDLT, but with more biliary complications.
Hepatic artery thrombosis (HAT) is the most serious vascular complication after liver transplantation. Multiple risk factors have been identified to impact its development. Changes in haemostasis associated with end stage liver disease and the disturbance of the coagulation and anticoagulation cascades play an important role in development of this lethal complication. Early recognition and therapeutic intervention is mandatory to avoid its consequences. Pharmacological prophylaxis, by the use of antiplatelet or anticoagulant agents, is an important tool to reduce its incidence and prevent graft loss. Only a few studies have shown a clear benefit of antiplatelet agents in reducing HAT occurrence, however, these studies are limited by being retrospective and by inhomogeneous populations. The use of anticoagulants such as heparin is associated with an improvement in the outcomes mainly when used for a high-risk patients like living related liver recipients. The major concern when using these agents is the tendency to increase bleeding complications in a setting of already unstable haemostasis. Hence, monitoring of their administration and careful selection of patients to be treated are of great importance. Well-designed clinical studies are still needed to further explore their effects and to formulate proper protocols that can be implemented safely.
Hepatic artery pseudoaneurysm after liver transplantation is an uncommon but potentially lethal complication. Early diagnosis and treatment are essential to avoid life-threatening hemorrhage in these patients. We herein report the case of three patients who developed hepatic artery pseudoaneurysms after living donor liver transplantation. Two patients presented with massive duodenal bleeding secondary to erosion of the hepatic artery into the bile duct, and one patient presented with intra-abdominal bleeding. These patients were managed by catheter-based minimal invasive endovascular procedures including coil embolization and stent grafting. All the patients were treated successfully with uneventful recovery. This technique can be considered as an effective treatment option for hepatic artery pseudoaneurysms instead of a difficult surgical intervention.
A recent mandate emphasizes severity of liver disease to determine priorities in allocating organs for liver transplantation and necessitates a disease severity index based on generalizable, verifiable, and easily obtained variables. The aim of the study was to examine the generalizability of a model previously created to estimate survival of patients undergoing the transjugular intrahepatic portosystemic shunt (TIPS) procedure in patient groups with a broader range of disease severity and etiology. The Model for End-Stage Liver Disease (MELD) consists of serum bilirubin and creatinine levels, International Normalized Ratio (INR) for prothrombin time, and etiology of liver disease. The model's validity was tested in 4 independent data sets, including (1) patients hospitalized for hepatic decompensation (referred to as "hospitalized" patients), (2) ambulatory patients with noncholestatic cirrhosis, (3) patients with primary biliary cirrhosis (PBC), and (4) unselected patients from the 1980s with cirrhosis (referred to as "historical" patients). In these patients, the model's ability to classify patients according to their risk of death was examined using the concordance (c)-statistic. The MELD scale performed well in predicting death within 3 months with a c-statistic of (1) 0.87 for hospitalized patients, (2) 0.80 for noncholestatic ambulatory patients, (3) 0.87 for PBC patients, and (4) 0.78 for historical cirrhotic patients. Individual complications of portal hypertension had minimal impact on the model's prediction (range of improvement in c-statistic: <.01 for spontaneous bacterial peritonitis and variceal hemorrhage to ascites: 0.01-0.03). The MELD scale is a reliable measure of mortality risk in patients with end-stage liver disease and suitable for use as a disease severity index to determine organ allocation priorities.
Background:
Venous drainage of the right paramedian sector (segments V and VIII), which is mainly via the middle hepatic vein (MHV), remains the major concern when using a right liver graft in living donor liver transplantation (LDLT). We herein describe our approach to decision making in the reconstruction of MHV tributaries in LDLT using a right liver graft without the MHV trunk.
Methods:
A total of 77 consecutive right liver LDLTs were performed between January 2011 and December 2012. The MHV trunk was not taken with the graft, and all MHV tributaries were ligated during donor hepatectomy. The right liver graft was subsequently assessed on the back table for congestion in the right paramedian sector as an indicator for the need to reconstruct MHV tributaries.
Results:
Based on the algorithm, reconstruction of MHV tributaries was performed in 18 patients (23.4 %). Although a mild degree of congestion in the right paramedian sector was noted in a few liver grafts without venous reconstruction, this congestion was well tolerated by recipients and was not visible afterward. The recipients' outcomes were similar in groups with and without venous reconstruction, and the 1-year survival rates were 83.3 and 86.2 %, respectively.
Conclusion:
A right liver graft without the MHV trunk can be successfully performed in LDLT with a satisfactory outcome. However, these experiences show that this approach might be safely applied as a strategy for determining the necessity of reconstruction of MHV tributaries in a right liver graft without the MHV trunk in LDLT.
Hepatic artery thrombosis (HAT) represents a major cause of graft loss and mortality after liver transplantation (LT). It occurs in 1.5-10% of adult recipients. Early diagnosis of HAT decreases septic complications, multiple organ failure (MOF) and graft loss with better outcome after treatment. In this study, we reviewed 102 episodes of HAT which classified as "Early" HAT if diagnosed before 3 weeks. The overall incidence of HAT was 6.8%, 31 (30%) were identified as early (E-HAT) HAT and 71 (70%) episodes as late (L-HAT) HAT. Graft dysfunction was the commonest presentation in 30 (29%) cases. Most E-HAT cases were managed by re-transplantation (74%), while early revascularization was carried out only in 13% with a 75% success rate. The incidence of re-transplantation in L-HAT was only 42%, while 32% were too ill for relisting and eventually died. Successful conservative management was noted in 13/102 (13%) patients with collateralization and good hepatic perfusion, with biliary complications encountered in 7 (54%) cases subsequently. Multivariate analysis showed that: previous episodes of HAT, number of arterial anastomoses, and low donor weight were independent risk factors for E-HAT, while history of upper abdominal operations (Non-HAT), previous history of HAT, low donor weight and recipients <50 years were independent risk factors for L-HAT. Graft survival for HAT patients was 52%, 36.6% and 27.4% for 1, 3 and 5 years compared to 81.4%, 81.2%, and 76.4% among non HAT patients respectively. In conclusion, prompt revascularization in early HAT decreases the incidence of irreversible serious septic complications and graft loss with improved overall outcomes. A significant number of late HAT patients do not require further intervention despite the high incidence of ischaemic cholangiopathy. Liver Transpl , 2014. © 2014 AASLD.
In partial liver transplantation, reconstruction of the hepatic artery is technically highly demanding and the incidence of arterial complications is high. We attempted to identify the risk factors for anastomotic complications after hepatic artery reconstruction and examined the role of multidetector-row computed tomography (MDCT) in the evaluation of the reconstructed hepatic artery in liver transplant recipients.
A total of 109 adult-to-adult living donor liver transplantations (LDLT) were performed at our institute between 1999 and July 2011. Hepatic artery reconstruction was performed under a surgical microscope (MS group, n = 84), until we began to adopt surgical loupes (4.5×) for arterial reconstructions in all cases after January 2009 (SL group, n = 25). A dynamic MDCT study was prospectively carried out on postoperative days 7, 14, and 28, and at postoperative month 3, 6, and 12 after April 2005 (n = 60).
There were no cases of hepatic artery thrombosis and six cases (5.5 %) of interventional radiology-confirmed hepatic artery stenosis (HAS). Risk factor analysis for HAS showed that ABO-incompatible LDLT was associated with HAS. Use of surgical loupes provided superior results as compared to anastomosis under a surgical microscope, and it also provided the advantage of reduced operative time. The MDCT procedure was useful for detecting HAS; however, the false positive rate was relatively high until 3 months after the LDLT (100 % sensitivity and 72.8 % specificity at 3 months).
Hepatic arterial anastomosis using surgical loupes tended to be time-saving and to yield similar or better results than traditional microscope-anastomosis. The use of MDCT aided the diagnosis of HAS, although the substantial false positive rate should be borne in mind in clinical practice.
In liver transplantation, microsurgical reconstruction of a hepatic artery is essential but requires challenging techniques. Especially in living-donor liver transplantation, the recipient artery is short and located deep in the abdominal cavity. Furthermore, hepatic artery thrombosis (HAT) can be a lethal complication. This study sought to uncover the risk factors for HAT after microsurgical vascular reconstruction.
From 1991 to 2011, we performed 151 microsurgical vascular reconstructions, including 3 deceased-donor liver transplantations. We retrospectively investigated the cases, performing univariate and multivariate analyses to identify independent risk factors for HAT. The patients had undergone ultrasonographic examinations for HAT over the first 14 days after transplantation.
Upon univariate analysis, the risk factors identified to be associated with P < .20 were young age (P = .0484), low body weight (P = .0466), short height (P = .0128), high graft-to-recipient weight ratio (P = .0031), small liver graft volume (P = .0416), small amounts of gabexate mesilate infusion (P = .0516), and the conventional technique (without a back-wall support suture; P = .1326). A multiple logistic regression analysis identified low body weight to be the only independent risk factor for HAT.
On the univariate analysis, we found that using the back-wall support suture technique contributed to the reduction of HAT, whereas on multivariate analysis, the only independent risk factor for HAT was low body weight.
A recent mandate emphasizes severity of liver disease to determine priorities in allocating organs for liver transplantation and necessitates a disease severity index based on generalizable, verifiable, and easily obtained variables. The aim of the study was to examine the generalizability of a model previously created to estimate survival of patients undergoing the transjugular intrahepatic portosystemic shunt (TIPS) procedure in patient groups with a broader range of disease severity and etiology. The Model for End-Stage Liver Disease (MELD) consists of serum bilirubin and creatinine levels, International Normalized Ratio (INR) for prothrombin time, and etiology of liver disease. The model's validity was tested in 4 independent data sets, including (1) patients hospitalized for hepatic decompensation (referred to as “hospitalized” patients), (2) ambulatory patients with noncholestatic cirrhosis, (3) patients with primary biliary cirrhosis (PBC), and (4) unselected patients from the 1980s with cirrhosis (referred to as “historical” patients). In these patients, the model's ability to classify patients according to their risk of death was examined using the concordance (c)-statistic. The MELD scale performed well in predicting death within 3 months with a c-statistic of (1) 0.87 for hospitalized patients, (2) 0.80 for noncholestatic ambulatory patients, (3) 0.87 for PBC patients, and (4) 0.78 for historical cirrhotic patients. Individual complications of portal hypertension had minimal impact on the model's prediction (range of improvement in c-statistic: <.01 for spontaneous bacterial peritonitis and variceal hemorrhage to ascites: 0.01-0.03). The MELD scale is a reliable measure of mortality risk in patients with end-stage liver disease and suitable for use as a disease severity index to determine organ allocation priorities.
Left liver grafts have been widely utilized in adult liver transplantation (LT) and yielded acceptable results. However, the conventional orthotopic implantation of a left liver graft imposes the potential risk of perioperative vascular complications. We report herein an alternative modified technique for adult left liver LT and evaluate its feasibility in LT. In this study, 10 recipients had their left liver graft rotated 180°, and heterotopically implanted at the right subphrenic space, which we termed "left at right" liver transplantation (LAR-LT). The sequence of vascular and biliary reconstruction was performed as standard techniques, and no perioperative vascular complications related to LAR-LT were encountered. There were two mortalities in this series, one due to a small-for-size graft dysfunction and the other due to postoperative internal hemorrhage. Two recipients had biliary strictures that were successfully managed by percutaneous biliary dilatation and Roux-en-Y hepaticojejunostomy. The clinical characteristics and outcomes of patients undergoing LAR-LT were also compared with patients undergoing conventional orthotopic left liver LT (n = 14). Although the results showed no significant difference between the two groups, according to our experience, the satisfactory outcome and easier technical reconstruction suggest that the LAR-LT modification could be a feasible alternative to left liver LT.