An early single-center experience of portal vein thrombosis in living donor liver transplantation: Clinical feature, management and outcome

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DOI: 10.4174/jkss.2011.81.1.35 · Source: PubMed
  • 12.83 · Catholic University of Daegu
  • 24.55 · Kyungpook National University School of Medicine, Kyungpook National University Hospital, South Korea, Daegu
Abstract
Portal vein thrombosis (PVT) has been considered a relative contraindication for living donor liver transplantation (LDLT). However, it is no longer a contraindication of LDLT due to improvement in surgical techniques and approaches to PVT. The aim of this study was to assess the impact of PVT on outcomes in LDLT patients. We retrospectively analyzed the data from 97 adult patients undergoing LDLT in our center from July 2008 to June 2010. Intraoperative findings and preoperative imaging results were reviewed for PVT grading (Yerdel grading). We analyzed the technical aspects and comparisons of risk factors, perioperative variables, and survivals between patients with and without PVT based on the grades. In the 97 LDLT patients, 18 patients were confirmed to have PVT (18.5%) including grade I cases (n = 8), grade II (n = 7), and grade III (n = 3). Prior treatment of portal hypertension was found to be an independent risk factor for PVT (P = 0.001). The comparisons between PVT and no PVT groups showed no significant difference in intraoperative and postoperative variables except for postoperative bleeding (P = 0.036). The short-term portal vein patency, in-hospital mortality and survival rates were not significantly different between the PVT and control groups. The outcomes are similar to non-PVT group in terms of in-hospital mortality, survival rates, and postoperative complications. Therefore, our study suggests that PVT cannot be considered to be a contraindication for LDLT and LDLT could be undertaken without increased morbidity and mortality in patients with PVT, in spite of operative complexity.
ORIGINAL ARTICLE
Copyright © 2011, the Korean Surgical Society
J Korean Surg Soc 2011;81:35-42
DOI: 10.4174/jkss.2011.81.1.35
JKSS
Journal of the Korean Surgical Society
pISSN 2233-7903eISSN 2093-0488
Received October 29, 2010, Accepted May 17, 2011
Correspondence to: Dong Lak Choi
Division of Hepatobiliary and Transplantation Surgery, Department of Surgery, Catholic University of Daegu School of Medicine, 3056-6
Daemyeong 4-dong, Nam-gu, Daegu 705-718, Korea
Tel: 82-53-650-4063, Fax: 82-53-650-4950, E-mail: dnchoi@cu.ac.kr
cc Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use,
distribution, and reproduction in any medium, provided the original work is properly cited.
An early single-center experience of portal vein
thrombosis in living donor liver transplantation:
clinical feature, management and outcome
Joo Dong Kim, Dong Lak Choi, Young Seok Han
Division of Hepatobiliary and Transplantation Surgery, Department of Surgery, Catholic University of Daegu School of Medicine,
Daegu, Korea
Purpose: Portal vein thrombosis (PVT) has been considered a relative contraindication for living donor liver transplantation
(LDLT). However, it is no longer a contraindication of LDLT due to improvement in surgical techniques and approaches to
PVT. The aim of this study was to assess the impact of PVT on outcomes in LDLT patients. Methods: We retrospectively ana-
lyzed the data from 97 adult patients undergoing LDLT in our center from July 2008 to June 2010. Intraoperative findings and
preoperative imaging results were reviewed for PVT grading (Yerdel grading). We analyzed the technical aspects and com-
parisons of risk factors, perioperative variables, and survivals between patients with and without PVT based on the grades.
Results: In the 97 LDLT patients, 18 patients were confirmed to have PVT (18.5%) including grade I cases (n = 8), grade II (n =
7), and grade III (n = 3). Prior treatment of portal hypertension was found to be an independent risk factor for PVT (P = 0.001).
The comparisons between PVT and no PVT groups showed no significant difference in intraoperative and postoperative var-
iables except for postoperative bleeding (P = 0.036). The short-term portal vein patency, in-hospital mortality and survival
rates were not significantly different between the PVT and control groups. Conclusion: The outcomes are similar to non-PVT
group in terms of in-hospital mortality, survival rates, and postoperative complications. Therefore, our study suggests that
PVT cannot be considered to be a contraindication for LDLT and LDLT could be undertaken without increased morbidity
and mortality in patients with PVT, in spite of operative complexity.
Key Words: Portal vein, Thrombosis, Liver transplantation, Outcome assessment
INTRODUCTION
In the early period of liver transplantation (LT), portal
vein thrombosis (PVT) was considered a contraindication
for operation because of the technical difficulties it en-
tailed, especially the inability to gain an adequate portal
supply [1-3]. In 1985, Shaw et al. [4] reported the first suc-
cessful deceased donor liver transplantation (DDLT) for a
PVT patient and since then, many innovative surgical
techniques have been introduced such as thrombectomy,
portal vein (PV) reconstruction using vein grafts, and cav-
oportal hemitransposition [5-9]. Current PVT patients are
no longer regarded to be contraindicated for LT and the re-
sults for patients with PVT is now comparable to that of
Joo Dong Kim, et al.
36
thesurgery.or.kr
patients without PVT [1,2,9,10]. Nevertheless, PVT is con-
sidered to add high risk to LT because of the complexity of
LT procedures, resulting in significant surgical morbidity
and mortality [10,11].
In living donor liver transplantation (LDLT), the issue
of subjecting a healthy donor to potentially significant
morbidity and mortality has led to a critical reassessment
of the recipient selection criteria that are considered ac-
ceptable in DDLT [12]. In addition, there are some techni-
cal difficulties due to these innovations for preexisting
PVT patients; necessity of distal dissection of vascular
pedicle of the hilum and restricted availability of deceased
donor vein graft [10,11].
Therefore, based on greater technical difficulties and
the results from DDLT in this group of patients, the pres-
ence of PVT has often been considered to be a relative or
absolute contraindication in LDLT [13,14].
From this point of view, the purpose of this report is to
analyze single-center experiences in management of PVT,
and to assess the impact of PVT on the outcomes in adult
LDLT patients.
METHODS
We retrospectively studied the records of 97 LDLT pa-
tients using data collected prospectively among 109 cases
of consecutive adult LDLT performed at our center from
July 2008 to June 2010. In our center, PVT has not been a
contraindication for LDLT except where the preoperative
radiologic studies demonstrate a gross tumor thrombus in
the main portal vein. All PVT patients were diagnosed us-
ing abdominal computed tomography (CT) performed
within 3 months before transplantation, and intra-
operative detection. For standardization purposes, 12 pa-
tients were excluded for the following reasons: 1) no avail-
ability of preoperative and postoperative CT scans, 2) in-
sufficient records of the intraoperative findings, or 3) tu-
mor thrombus confirmed by postoperative pathology.
PV flow was monitored routinely after transplantation
by Doppler ultrasound at post-transplant days 1,4, and 7,
and dynamic CT scan at days 14 and 21.
PVT was diagnosed preoperatively and/or intra-
operatively in 18 cases (18.5%). These patients with pre-
operatively and/or intraoperatively confirmed PVT formed
the study group. Patients without PVT and transplanted
during the same period were used as the control group.
All patients with confirmed PVT were retrospectively
classified into four grades according to the extent of
thromboses, as described by Yerdel et al. [15]: Grade I:
minimally or partially thrombosed PV, in which the
thrombus is mild or, at the most, confined to 50% of the
vessel lumen with or without minimal extension into the
superior mesenteric vein (SMV). Grade II showed 50%
occlusion of the PV, including total occlusion with or with-
out minimal extension into the SMV. Grade III were com-
plete thromboses of both PV and proximal SMV with an
open distal SMV. Grade IV was complete thrombosis of the
portal vein as well as the proximal and distal SMV.
The preoperative, intraoperative, and postoperative pa-
rameters in these two groups were compared. The patients
with PVT and those with non-PVT were followed up for a
median time of 15.3 months (range, 1.2 to 36.5 months) and
14.9 months (range, 2.4 to 36.3 months).
Assessment of risk factors for PVT and outcomes
analysis
Analyzed potential risk factors for PVT included; age,
sex, primary disease or Child-Turcott-Pugh (CTP) score,
the average model for end-stage liver disease (MELD)
sore, preoperative platelet count, preoperative pro-
thrombin time, living donor characteristics, quality of do-
nated liver, previous treatment for portal hypertension
(splenectomy, shunt operation, transjugular intrahepatic
portosystemic shunt [TIPS], or sclerotherapy), and pres-
ence of malignancy.
Surgery time, amount of operative red blood cell (RBC)
transfusion, duration of hospital and intensive care unit
(ICU) stays were analyzed. Postoperative complications
(postoperative bleeding, biliary complication, PVT or
stenosis, hepatic artery complication, infection, rejection)
were compared. In-hospital mortality and patient survival
were compared according to the presence of PVT.
Statistical analysis
Continuous variables are represented as a mean ± SD
An early single-center experience of portal vein thrombosis in living donor liver transplantation
thesurgery.or.kr
37
Ta ble 1 . Recipient, donor, and graft characteristics of LDLT in patients with and without PVT
PVT (n = 18) Non-PVT (n = 79) P-value
Age (yr) 50.8 ± 7.3 50.5 ± 8.2 0.791
Recipient gender (M:F) 14:4 57:22 0.627
Primary disease
HBV/HCV related liver cirrhosis without HCC 9 (50.0) 28 (35.4) 0.289
HBV/HCV related liver cirrhosis with HCC 5 (27.8) 31 (39.2) 0.428
Alcoholic liver cirrhosis 2 (11.1) 12 (15.2) 0.99
Others
a)
2 (11.1) 8 (10.2) 0.99
CTP score 9.1 ± 1.8 8.7 ± 2.8 0.620
MELD score 17.3 ± 8.1 17.7 ± 10.3 0.831
Ascites (mL) 1,261.1 ± 1,440.2 1,383.5 ± 1,892.8 0.964
Preoperative platelet (×10
3
/μL) 55.1 ± 31.3 68.9 ± 27.7 0.243
Preoperative prothrombin time (INR) 1.88 ± 0.63 1.92 ± 0.88 0.639
Previous treatment of portal HTN (Y:N) 6:12 5:74 0.014
Donor age (yr) 30.0 ± 7.7 27.7 ± 7.9 0.238
Donor gender (M:F) 10:9 58:22 0.159
Graft fatty change (%) 1.11 ± 3.66 2.72 ± 5.23 0.111
Graft-to-recipient weight ratio (%) 0.98 ± 0.19 1.06 ± 0.25 0.151
Type of graft
Single (right/left liver) 13:4 70:8 0.129
Dual 1 1 0.338
Values are presented as mean ± SD or number (%).
LDLT, living donor liver transplantation; PVT, portal vein thrombosis; HBV, hepatitis B virus; HCV, hepatitis C virus; HCC, hepatocellular
carcinoma; CTP, Child-Turcott-Pugh; MELD, the average model for end-stage liver disease; INR, international normalized ratio; HTN,
hypertension; Y, yes; N, no.
a)
Cryptogenic liver cirrhosis, fulminent hepatic failure, primary biliary cirrhosis.
and categorical data were analyzed using the Fishers ex-
act test. A Mann-Whitney U test was used to compare the
group means. The Kaplan-Meier method was used to es-
timate survival curves, and survival curves were com-
pared by means of the log-rank test. All analyses were
carried out using SPSS ver. 14.0 (SPSS Inc., Chicago, IL,
USA). A P-value less than 0.05 was considered
significant.
RESULTS
Incidence and grading of PVT
PVT was diagnosed in 18 of the total 97 adult patients
(18.5%) who underwent LDLT including 8 cases (44.4%) of
grade I; 7 (38.9%) of grade II; 3 (16.7%) of grade III.
Preoperative risk factors for PVT (Table 1)
Age, gender, primary disease, CTP score, MELD score,
presence of hepatocellular carcinoma (HCC), ascites, pre-
operative platelet count, and prothrombin time showed
no relationship to PVT (P 0.05). Living donor character-
istics and quality of donated liver had no significant differ-
ences between the two groups. However, previous treat-
ment of portal hypertension (splenectomy, shunt oper-
ation, TIPS, sclerotherapy) was associated with PVT (P =
0.014).
Intraoperative and postoperative variables be-
tween PVT and non-PVT groups (Table 2)
The mean duration of operation in the patients with
PVT (598.2 ± 115.4 minutes) was longer than in those with-
out PVT (572.6 ± 97.6 minutes), but this was not statisti-
cally significant (P = 0.483). The overall mean RBC trans-
fusion requirement in the patients with PVT (1,018.2 ±
816.2 mL) was not significantly different to that in those
without PVT (1,203.7 ± 1,021.7 mL, P = 0.485). The mean
ICU stay was similar in both groups (4.47 ± 1.12 days vs.
5.32 ± 5.6 days, P = 0.632). The mean hospital stay was also
similar (32.2 ± 11.6 days vs. 34.5 ± 23.1 days, P = 0.612).
Joo Dong Kim, et al.
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Ta ble 2 . Comparative analysis of operative and postoperative variables with or without PVT
PVT (n = 18) Non-PVT (n = 79) P-value
Operation time (min) 598.2 ± 115.4 572.7 ± 97.6 0.483
RBC transfusion (mL) 1,018.2 ± 816.2 1,203.7 ± 1,021.7 0.485
ICU stay (day) 4.47 ± 1.18 5.32 ± 5.64 0.632
Admission stay (day) 32.24 ± 11.61 34.52 ± 23.06 0.612
Postoperative complications (%)
Postoperative bleeding 22.2 6.3 0.049
Biliary complication (biliary stricture, bile leak) 27.8 21.5 0.529
Infection (regardless type) 16.1 10.1 0.405
Portal vein complication (stenosis, rethrombosis) 5.6 2.5 1.000
Hepatic artery complication (stenosis, thrombosis) 0 5.1 0.582
Rejection 5.6 1.3 0.324
PVT, portal vein thrombosis; RBC, red blood cell; ICU, intensive care unit.
Fig. 1. Survival curves in the portal vein thrombosis (PVT) and non-PVT groups (A), and in the PVT and non-PVT groups after excluding
malignancy (B).
Postoperative complications of PVT patients (Table 2)
The incidence of postoperative bleeding in the patients
with PVT was significant higher than in those without
PVT (22.2% vs. 6.3%, P = 0.049). But, the rate of portal vein
rethrombosis or stenosis, hepatic artery complication, in-
fection, biliary complication (bile leak, biliary stricture),
and rejection were similar in the PVT and non-PVT
groups.
PV patency and patient’s survival of PVT group
The PV patency of the PVT group in their follow-up pe-
riod was similar to the non-PVT group. Only one of the pa-
tients with PVT developed a rethrombosis. A relapar-
otomy and intraoperative PV stenting were performed at
the 13th day after transplantation.
The in-hospital mortality for patients with PVT was
similar to that of patients without PVT (5.6% vs. 3.8%, P
= 0.548). The 1-and 3-year actuarial survival rate in the
PVT group were 87.7% and 75.2%, respectively, but
there was no statistical difference between the PVT
group and the non-PVT groups (log-rank test, P = 0.357)
(Fig. 1A).
Considering the influence of HCC on survival, we ex-
cluded patients with cancer from both groups, leaving 36
patients in the PVT group and the controls, still there was
no significant difference between the two groups
(log-rank test, P = 0.979) (Fig. 1B).
An early single-center experience of portal vein thrombosis in living donor liver transplantation
thesurgery.or.kr
39
Ta ble 3 . Surgical procedures for thrombectomy and reconstruction as grade
Grade No. Treatment Outcome
I 8 Simple thrombectomy (n = 3) IOP PV stent (n = 1)
Eversion thrombectomy (n = 3)
II 7 Eversion thrombectomy (n = 6) Uneventful
PV reconstruction with interposition graft (n = 1)
III 3 Eversion thrombectomy (n = 1) Uneventful
PV reconstruction with interposition graft/PV stent (n = 1)
RP-A (n = 1)
IOP, intraoperative; PV, portal vein; RP-A, renoportal anastomosis.
Fig. 2. Portal vein (PV) reconstruction with interposition vein graft in case of failed eversion thrombectomy. Preoperative computed
tomography (CT) scan of this case showed that portal vein is completely obstructed (white arrow) and PV thrombosis propagated to
portomesenteric junction (A). Interposition vein graft was used for portal vein reconstruction (B) and intraoperative PV stenting (black arrow)
was performed due to residual thrombus (C). Patency of interposition graft was demonstrated by postoperative CT scan (D).
Operative management
Surgical management of PVT was dependent on the
characteristics of the thrombus; its size (partial or com-
plete) or extension degree through the portal venous
system. Surgical procedures for PVT are shown in Table 3.
Most patients with grade I and II thrombosis were man-
Joo Dong Kim, et al.
40
thesurgery.or.kr
Fig. 3. Portal vein (PV) reconstruction with renoportal anas-
tomosis. Abdominal computed tomography (CT) scan showed
complete portal vein thrombosis extended to proximal superior
mesenteric vein (arrow) and marked dilated splenorenal shunt
drained into the left renal vein (arrow head) (A). Interposition graft
was anastomosed to upper border of left renal vein and the graft PV
is anastomosed to proximal end of the interposition graft (B). No
signs of portal vein system stenosis were visible in postoperative
abdominal CT scan (C).
aged with classic PV-PV anastomosis with or without sim-
ple thrombectomy or eversion thrombectomy. In only one
patient with grade II, an interposition iliac vein graft was
used as anastomosis between the donors PV to the recipi-
ent’s proximal portal vein nearby the spleno-portal junc-
tion because the hilum had severe fibrotic change due to a
previous hepatectomy where the thromboses were not
completely removed.
One patient with grade III thrombosis was successfully
treated with eversion thrombectomy after lower dis-
section and classic PV-PV anastomosis. However, the oth-
er two cases failed complete eversion thrombectomy, and
had no suitable PV to perform the classic anastomosis. In
one of these cases, interposition iliac vein graft was used
for PV reconstruction. And, in addition, intraoperative PV
stenting was performed because there was residual
thrombus at the spleno-mesenteric junction and proximal
SMV (Fig. 2).
In the other case with complete and extended occlusion
of the SMA and a large splenorenal shunt, renoportal anas-
tomosis was performed in a side-to-end fashion (Fig. 3).
DISCUSSION
The PVT is a well-established complication among pa-
tients with end-stage liver disease, and its incidence rang-
es from 2 to 26% in various centers [8,14], reaching as high
as 39% in certain patient populations [16]. The incidence of
PVT in LDLT patients at our center was 18.5%.
The etiology is not completely understood, but is be-
lieved to be related to anatomic change in the liver owing
An early single-center experience of portal vein thrombosis in living donor liver transplantation
thesurgery.or.kr
41
to the cirrhotic process, increased portal pressure, endo-
thelial injury or coagulation changes [1,15,17,18]. In past
studies, high-risk factors for developing PVT included au-
toimmune hepatitis, cryptogenic cirrhosis, chronic active
hepatitis, Budd-Chiari syndrome, male gender, increased
age, trauma, hypercoagulative states, Child-Pugh C, and
treatment of portal hypertension (splenectomy, shunt op-
eration, TIPS) [4,14,15,19]. But, this study found that pre-
vious treatment of portal hypertension was an in-
dependent risk factor for PVT prior to LDLT.
PVT was considered for 2 decades to be an absolute con-
traindication for LT [17]. However, in 1985, two successful
liver transplantations were reported despite PVT [4]. Since
then, progress in LT has allowed surgeons to utilize multi-
ple techniques including thrombectomy of native veins,
extensive thromboendovenectomy up to splenomesen-
teric confluence, venous interposition graft, renoportal
anastomosis, cavoportal hemitransposition for over-
coming this major problem and restoring PV flow
[6,15,20,21]. But, there are some problems with technical
difficulties and restricted availability of vein graft in LDLT
as of yet [10,11,18]. The ideal surgical technique to resolve
PVT during LT is not defined. The treatment depends on
the characteristics of thrombosis (whether acute or chron-
ic), degree (partial or complete), and especially, degree of
extension to the splanchnic venous system [1,17].
In our study, 93.3% (n = 14) of patients with grade I and
II PVT were successfully managed by classic PV-PV anas-
tomosis with or without simple or eversion throm-
bectomy. In only one patient with grade II PVT, we per-
formed thrombosed PV resection and portal vein re-
construction using interposition vein graft between the
donors PV and the recipient’s proximal PV close to sple-
no-portal junction because of severe porta hepatis fibrotic
change and incomplete eversion thrombectomy.
In one grade III PVT patient eversion thrombectomy
failed, interposition vein graft was used and intra-
operative PV stenting was performed due to residual
thrombus at portomesenteric confluence level. And in the
other case of grade III PVT with large splenorenal shunt,
we experienced portal vein reconstruction using an inter-
position iliac vein graft connected to the left renal vein in a
side-to-end fashion.
Regarding to blood transfusion, operation time, and
in-hospital stay including ICU stay, no statistical differ-
ence was observed between the PVT and non-PVT groups
in our study, indicating that proper management of PVT is
a controllable procedure of LDLT.
The greater technical difficulty in patients with pre-ex-
isting PVT has demonstrated an increased risk of compli-
cations like hepatic artery thrombosis, relaparotomy, post-
operative pancreatitis, sepsis, and renal failure in the dif-
ferent studies [9,15,22]. In our center, comparisons of the
PVT patients and controls showed no statistical differ-
ences except postoperative bleeding. This increased risk is
related to pre-existing PV pathology, high blood loss, the
development of coagulopathy and severe acidosis [23].
Therefore, meticulous operative procedures and close
monitoring for postoperative bleeding are required.
Initially, patients with PVT undergoing LT showed a
high mortality rate in some papers [24]. But, recent studies
such as that of Lladó et al. [25] have described similar sur-
vival in patients with PVT compared to patients without
PVT. In our study, the results (in-hospital mortality, 1-and
3-year survival rates) obtained in patients undergoing
LDLT with preoperative PVT are not significantly differ-
ent to patients without PVT, despite short-term follow-up.
Moreover, PVT of grade II to III can be managed with dif-
ferent techniques, with good postoperative results. The re-
sults suggest that accurate preoperative evaluation and
detailed surgical planning are essential for restoring PV
patency in LDLT patients.
In conclusion, the results are similar to non-PVT group
in terms of in-hospital mortality, survival rates, and post-
operative complications, and PV patency. Therefore, our
experience suggests that PVT cannot be considered to be a
contraindication for LDLT in spite of operative com-
plexity.
In PVT of grade II and III, LDLT could be undertaken
successfully with accurate preoperative diagnosis and
proper surgical techniques and good postoperative out-
comes can be obtained. Furthermore, innovations of ther-
apeutic approaches and accumulation of experience could
be required to improve the outcomes in LDLT with the
more extensive PVT patients.
Joo Dong Kim, et al.
42
thesurgery.or.kr
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article
was reported.
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plantation: influence on morbidity and mortality. Clin
Transplant 2007;21:716-21.
    • "One paper reported a statistically significantly lower in-hospital survival rate in the LT recipients with PVT than in those without PVT (68% versus 87.6%) [16], but another paper reported a statistically similar in-hospital survival between the two groups (90.9% versus 91.4%) [18]. Two studies, in which LT was performed after 2000, compared the in-hospital survival between the LT recipients with and without PVT [28, 37]. Both of them reported a statistically similar in-hospital survival between the two groups (95.5% versus 90.9%; 94.4% versus 96.2%). "
    [Show abstract] [Hide abstract] ABSTRACT: Portal vein thrombosis (PVT) increases the technical complexity of liver transplantation (LT). This systematic review and meta-analysis aim to analyze the association of pre-LT PVT with the overall survival after LT. PubMed, EMBASE, and Cochrane library databases were used to search for papers related to the association between pre-LT PVT and survival of LT recipients. The differences in the survival rates between the LT recipients with and without pre-LT PVT were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Twenty-seven papers were included. Overall meta-analysis showed that the total LT recipients with pre-LT PVT had a significantly lower 1-year survival rate than those without pre-LT PVT (OR=0.733, 95%CI=0.621-0.865; P=0.0002). But no statistically significant difference was observed in the in-hospital (OR=0.713, 95%CI=0.343-1.482; P=0.365), 1-month (OR=0.679, 95%CI=0.345-1.333; P=0.261), or 5-year survival rate (OR=0.788, 95%CI=0.587-1.058; P=0.113). Additionally, the 1-year survival rate was significantly lower in the LT recipients with complete PVT than in those without PVT (OR=0.503, 95%CI=0.295-0.858; P=0.012). However, no statistically significant difference in the 1-year survival rate between them was observed in the meta-analysis of high-quality studies (OR=0.899, 95%CI=0.657-1.230; P=0.505) or that of studies in which LT was performed after 2000 (OR=0.783, 95%CI=0.566-1.083; P=0.140). Pre-LT PVT, especially complete PVT, decreased the 1-year survival rate after LT. However, the detrimental effect of pre-LT PVT on the survival of LT recipients became inconclusive in high-quality studies. Additionally, further well-designed cohort studies should validate the association in patients undergoing LT during the latter years.
    Full-text · Article · Mar 2015
    • "Even though liver transplantation became the standard treatment for ESLD and early-stage HCC and the number of liver transplant programs is rapidly increasing all over the world, there are a limited number of recent publications about outcomes from new liver transplant programs [9,10,11]. "
    [Show abstract] [Hide abstract] ABSTRACT: Purpose To evaluate patient triage pattern and outcomes according to types of liver transplantation as part of a new liver transplant program developed in an East Asian country with a limited number of deceased donors. Methods Medical records of initial 50 liver transplantations were reviewed retrospectively. Results Twenty-nine patients underwent deceased donor liver transplantation (DDLT) and 21 patients underwent living donor liver transplantation (LDLT). Mean model for end-stage liver disease scores of recipients of DDLT and LDLT were 24.9 ± 11.6 and 13.1 ± 5.4, respectively (P < 0.0001). Twenty-eight patients had HCCs and 17 of them (60.7%) underwent LDLT, which was 80.9% of LDLTs. There were 2 cases of perioperative mortality; each was from DDLT and LDLT, respectively. Median follow-up was 18 months. Overall patient and graft survival rates at 6 months, 1 and 2 years were 95.7%, 93.4%, and 89.8%, respectively. There was no significant difference in survival between DDLT and LDLT. Overall recurrence-free survival rates of hepatocellular carcinoma (HCC) patients at 6 month, 1, and 2 years were 96.3%, 96.3%, and 90.3%, respectively. There was no significant difference in recurrence-free survival between DDLT and LDLT. Conclusion As a new liver transplant program with limited resource and waiting list, patients with critical condition could undergo DDLT whereas relatively stable patients with HCCs were mostly directed to LDLT. We recommend a balanced approach between DDLT and LDLT for initiating liver transplant programs.
    Full-text · Article · Jul 2014
  • [Show abstract] [Hide abstract] ABSTRACT: Diffuse porto-mesenteric thrombosis is considered to be a contraindication to living donor liver transplantation (LDLT) by numerous transplant centers. We report a successful case of LDLT with cavo-portal hemitransposition (CPHT) in a 36 year old male who presented with diffuse porto-mesenteric thrombosis and de-compensated end stage liver disease. Intraoperatively, the splenic artery was ligated to ameliorate portal hypertension and hypersplenism, and a LDLT with a right lobe graft was performed. In the presence of the porto-systemic collaterals, an end-to-end CPHT was fashioned, instead of a renoportal anastomosis, to provide portal inflow to the allograft. The graft to recipient body weight ratio was 1.06. The cold and warm ischaemia times were 119 and 64 minutes, respectively. Intraoperative Doppler ultrasonography of the allograft demonstrated good portal and arterial inflows with a normal venous outflow. Post-operatively, the patient had transient renal dysfunction that recovered gradually over a period of 19 days. He also had one episode of hematemesis due to persistent portal hypertension and required blood and platelet transfusions for pancytopenia due to hypersplenism. At follow-up after 26 months post-transplant, he is alive and well, his liver and renal functions tests are normal and CT angiography and Doppler ultrasonography showed a patent cavo-portal anastomosis with good flow. We have demonstrated that LDLT with CPHT can be performed safely in selected patients with diffuse port-mesenteric thrombosis. Key words: Portal vein thrombosis, Liver transplantation, Cavoportal hemitransposition, Portal hypertension
    Full-text · Article · Jan 2015
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