Video Transplant |
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VT01 Video Transplantation: Liver Transplantation |
Selection of Video Presentations from Abstract Submissions |
VT01-01 | Techniques for Overcoming Atrophic Changes of the Portal Vein in Adult Living Donor Liver Transplant Kwang-Woong Lee, Korea, Republic of
K.-W. Lee1, J.-M. Lee1,2, K. Hong1, E.S. Han1, S.K. Hong1, J. Byun1, N.-J. Yi1, K.-S. Suh1 1Department of Surgery, Seoul National University Hospital, Korea, Republic of, 2Seoul National University Hospital, Korea, Republic of
Background: Spontaneous diversion of portal flow through collateral vessels into the systemic circulation is frequently found in recipients with severe portal hypertension. These spontaneously induced main portal vein atrophic change and made flow into the collateral even after the implantation of the allograft. Such changes can make transplantation surgery difficult. We described several methods for overcoming this situation with appropriated surgical techniques. Methods: We performed living donor liver transplantation using 3 different anastomotic technique in the patients who had atrophic changes in the portal vein. Results: (1) Venoplasty for enlarging the diameter with own portal vein: we enlarged the diameter of the recipient portal vein using their own portal vein stump patch. (2) Conduit with cryopreserved vessels: we dissected around SMV-SV junction and made conduit using the cryopreserved vessels. (3) Left gastric varix to portal vein anastomosis: If the recipients had large gastric varix and the variceal wall was thick enough to the anastomosis, we used that varix to the anastomosis. Conclusions: It is important to select optimal methods of portal vein anastomosis in the patients with atrophic change on portal vein. If these methods are used properly, these three different methods could be a good option for overcoming each situation. |
VT01-02 | Management of Portal Vein Thrombosis in Deceased Donor Liver Transplantation: Technical Tips and Tricks Lucas McCormack, Argentina
L. McCormack, M. Balmer, M. Cobos, J. Devoto, D. Ramallo, E. Quiñonez Hospital Aleman of Buenos Aires, Argentina
Introduction: Portal vein (PV) thrombosis remains a challenge in liver
transplantation. Although laborious, many techniques for graft
revascularization and decompression of splanchnic territory have shown
encouraging results, making PV thrombosis no longer a contraindication for
liver transplantation.
Content Description: We present 4 particular scenarios where different options had been
adopted depending on the extent of the PV thrombosis and the abdominal vascular
anatomy based on preoperative imaging and intra-operative situation. We
demonstrate on a “How I do it” manner, how we overcome different clinical cases
using 4 techniques for PV revascularization including 1 thrombo-embolectomy
with Fogarty catheter into the superior mesenteric vein, 1 eversion
thrombo-endovenectomy for a calcified and recanalized PV thrombosis, 1 flow
reconstruction of the PV inflow using the left gastric vein for a patient with
extensive mesenteric thrombosis and selective left segmental portal
hypertension and, finally, 1 PV flow reconstruction using a jump-graft with
interposition of a donor iliac vein from the superior mesenteric vein to the
graft portal vein trunk for a patient with complete portal vein occlusion and
absence of portal flow. Conclusion: PV thrombosis no longer represents an absolute contraindication for liver
transplantation. Innovative intraoperative strategies are required to ensure
liver graft revascularization in patients with pre-existing or intraoperative
PV thrombosis. |
VT01-03 | Stapled Side-to-Side Cavo-Cavostomy for Deceased Donor Liver Transplantation Ravi Mohanka, India
R. Mohanka, A. Golhar, P. Rao, A. Shrimal, V. Nikam Department of Liver Transplant and HPB Surgery, Global Hospital, India
Side
to side cavo-cavostomy is one of the preferred methods amongst modified
piggyback techniques for deceased donor liver transplantation (DDLT). Staplers
have been used sparsely to create vascular anastomosis. This video depicts the
use of liner endoscopic vascular staplers for side to side cavo-cavostomy in
DDLT.
For
implantation using stapler technique we cross clamped inferior vena cava (IVC) in
standard fashion. Five-millimetre cavotomies are performed in caudal parts of
the posterior wall of donor IVC and anterior wall of recipient IVC. One arm of
the endoscopic vascular stapler is inserted into recipient IVC and the other
arm in the donor IVC. Putting stabilizing sutures to both inferior vena cava
before the anastomosis facilitates stapler jaws to be inserted into the vessel
lumen. A side-to-side cavo-caval anastomosis is performed by closing the two
stapler arms and firing the stapler. Remaining IVC opening is closed with a
running 5/0 polypropylene suture.
The
mean anastomosis time is reduced to four minutes with use of staplers compared
to fifteen to twenty minutes for sutured side to side cavo-caval anastomosis
thus reducing the anhepatic and warm ischemia time. This technique permits
surgeon to perform a quick, easy and consistent quality anastomosis even in a deep
operative field reducing. The reduced warm ischemia time can be beneficial to
decrease early allograft dysfunction, particularly with extended criteria
donors. |
VT01-04 | Split Liver Transplantation for Multiple Liver Adenomas in the Context of Agenesis of the Portal Vein with Type 1 Congenital Extrahepatic Portosystemic Shunt Lucas McCormack, Argentina
L. McCormack, D. Ramallo, A. Angeramo, C.M. Cobos, J. Devoto, M. Balmer, E. Quiñonez Hospital Aleman of Buenos Aires, Argentina
Introduction: Congenital extrahepatic portosystemic
shunt (CEPS) is highly complex congenital disorder and it could be associated with
other congenital anomalies like portal vein agenesis. Additionally, focal liver
lesions are an important clue to the underlying condition.
Content description:
A 17 years old female patients having a cerebellar agenesis
presented with enlargement of the liver secondary to multiples hepatic tumors. Due
to her congenital disorder, the presence of hepatic encephalopathy was
difficult to be addressed. CT scan and doppler ultrasound confirmed multiple arterial
hyperenhancing lesions, absence of intrahepatic portal blood flow and a 12
mm portacaval shunt.
Accurate typing of the shunt was achieved by angiography
and direct contrast injection into the shunt with balloon occlusion through trans-jugular
approach. The finding of a complete shunting of the portal blood via a
fistulous communication between main portal vein and inferior vena cava
confirmed a type 1 CEPS. After 1 year-follow up tumor progression within the
liver was detected in absence of elevation of tumor markers. As MELD score was
very low, additional points were requested and the patient was listed with 26 of
MELD. A liver transplantation was performed using a right liver (split including
segments 1 and 4). Transplantation was performed uneventful and without the
transfusion of any blood product. The patients was discharged on postoperative
day 5 without complications.
Conclusions: When dealing with type 1 CEPS, liver transplantation should
be reserved for patients developing features of hepatic encephalopathy or having
suspicious of malignant transformation of multiple liver adenomas. |
VT01-05 | Dealing with Severely Steatotic Liver Grafts for Donor Liver Transplantation: Aggressive Management of a Spontaneous Postoperative Giant Liver Hematoma Lucas McCormack, Argentina
D. Ramallo, A. Casas, M. Balmer, P. Mendez, L. McCormack Hospital Aleman of Buenos Aires, Argentina
Introduction: Donor steatotic grafts used for liver transplantation (LT) are
particularly vulnerable to ischemia/reperfusion injury, resulting in an
increased risk of postoperative morbidity and mortality.
Content description: A 63-year-old male patient underwent deceased donor liver
transplantation due to liver cirrhosis. The analysis of the liver graft
demonstrated severe fatty infiltration (70% microvesicular, 10%
macrovesicular). Transplant operation was performed uneventful. On POD 3, a
partial portal vein thrombosis was detected. A CT detected small focal liver
necrosis in segment 3 of the liver graft probably due to ischemic reperfusion
injury or surgical trauma on a fragile fatty liver. Subsequently,
anticoagulation therapy was initiated. On POD 8, the patient suffered abdominal
pain and become hemodynamically unstable. A CT showed a huge hematoma in the
left hepatic lobe with acute intra-hepatic bleeding. Arterial embolization of
the left hepatic artery was successfully performed. On POD 22 he was
re-admitted with symptoms related to an intra-abdominal collection. CT-guided
percutaneous drainage was performed of the infected liver hematoma. On POD 25,
patient persisted with fever and thus, a left lateral sectionectomy was
performed. Postoperative outcome was uneventful and was discharged on POD 5.
Conclusion: Spontaneous hepatic hemorrhage following LT is an uncommon but
life-threatening complication. Management should be conservative at first,
however, when these conditions are associated with infection or clinical deterioration,
especially in immunocompromised patients, the aggressive approach must be
performed. |
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