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.