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Early Venous Outflow Obstruction After Liver Transplantation and Treatment With Cavo-Cavostomy
Early Venous Outflow Obstruction After Liver Transplantation and Treatment With Cavo-Cavostomy J. Quintela, C. Fernández, J. Aguirrezabalaga, C. Gerardo, M. Marini, F. Suarez, and M. Gomez ABSTRACT Objective. The objective of this study was to describe by a retrospective analysis the evolution of patients who needed an end-to side cavo-cavostomy in addition to a previous cavo-caval anastomosis, during orthotopic liver transplantation (OLT), caused by hepatic venous outflow obstruction. Methods. We reviewed 673 consecutive OLT and the treatment and evolution of technique-related complications. Results. This study of 673 consecutive OLT, all with the piggyback modality included 23 cases (22 patients and 23 grafts) who underwent an additional cavo-caval anastomosis for venous outflow problems either perioperatively or during the immediate postoperative period. One patient developed an early and 3 developed a late, caval stenosis that was successfully treated using angioplasty. Five patients died postoperatively. Causes of death were sepsis (n ⫽ 3), thrombosis of a mesenteric bypass (n ⫽ 1), and massive hemorrhage (n ⫽ 1). Long time evolution was as follows: 2 patients died at 7 and 45 months, respectively, (viral relapse) and the other 15 subjects are alive and well.
RESULTS
the others had a patch constructed with 3 veins. The incidence of obstructive problems was 3.9% and 2.7%, respectively. Eight patients showed a decrease in the cardiac output, not related to reperfusion syndrome. We attribute this hemodynamic disturbance to inadequate graft size that compressed the caval anastomosis. One patient suffered a major caval tear that disabled the use of a suprahepatic patch; another patient suffered a stenosis of the cava, anatomic abnormalities of the retrohepatic vena cava. In both cases it was necessary to perform a wider anastomosis to guarantee venous outflow. All of the patients underwent an additional cavo-caval anastomosis connecting the infrahepatic caval end from the graft to the recipient caval trunk, in an end-to-side manner for 21 patients during transplantation and for 2 patients in the immediate postoperative time. In 1 case a “neo-bed”
Twenty-three grafts performed in 22 patients underwent an extra cavo-caval anastomosis. Indications for OLT in these patients are presented in Table 1. The distribution of these vena cavae complications is shown in Table 2. The incidence of acute occlusive venous return was 3.41% (23/673). A patch was made in the recipient cava by joining the middle and left hepatic veins in 7 patients, and
From the Departments of General Surgery (J.Q., C.F., J.A., C.G., M.G.), Interventional Radiology (M.M.), and Gastroenterology and Hepatology (F.S.), Hospital Juan Canalejo, A Coruña, Spain. Address reprint requests to Julia Quintela Fandiño, Cirugı´a General A, CHU Juan Canalejo Xubias de arriba, n° 84, 15006, A Coruña, Spain. E-mail: [email protected]
LL the orthotopic liver transplantations (OLT) performed in our center were performed using the “piggyback” technique (PB). Even though complications related to retrocaval dissection were reduced, specific problems were related to this technique, especially involving liver venous outflow obstruction.1 The objectives of this study were to describe, and analyze the treatment and the clinical courses of cases in which outflow obstruction was related to the PB.
A
MATERIALS Our retrospective study was based on data from 673 OLT performed in our hospital between 1994 and 2008. We systematically performed a cavo-caval anastomosis using the PB technique. We performed an end-to-side cavo-caval anastomosis in addition to the pre-existent connection in cases with acute venous return occlusion.
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.06.066
© 2009 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
2450
Transplantation Proceedings, 41, 2450 –2452 (2009)
CAVO-CAVOSTOMY
2451
was achieved by suturing Gerota’s capsule to the diaphragm. In 1 case we performed reconstruction of the falciform ligament. Twenty patients experienced an immediate improvement of hemodynamic condition or of graft congestion. One patient developed persistent ascites in the postoperative period. A cavography showed stenosis of the anastomosis, which was successfully treated using angioplasty. Three more patients developed late caval stenosis at 6 months, 1 year, or 2 years later, respectively. There were 5 deaths in the immediate postoperative period due to: sepsis (n ⫽ 3), massive thrombosis of a mesenteric-portal bypass with ischemic hepatitis of the graft (n ⫽ 1), and a massive hemorrhage due to spontaneous tear of a pseudoaneurysm of the celiac trunk (n ⫽ 1). Two more patients died at 7 and 45 months, respectively, both due to viral relapse. The other 15 subjects are well.
DISCUSSION
The PB technique has been used since it was described by Tzakis et al in 1989,2 because of its advantages compared with the caval-interposition technique. Not only does it avoid retrocaval blunt dissection reducing blood loss, but also it helps to maintain hemodynamic stability in the recipient due to the partial cavae clamping, making retransplantation easier.3 Specific complications are poorly described in the literature. Budd-Chiari and congestion of the graft are the most frequent perioperative and early postoperative complications.1,4 Several techniques have been described to improve graft venous outflow: elongation of the caval anastomosis by performing a cavaplasty, omentoplasy, rotation of the graft, or performing a second caval anastamosis.1,5–7 We systematically decided to add a second caval anastomosis in all cases that showed any degree of venous outflow obstruction. These problems may vary from simple rotation of the graft and twisting of the anastomosis with congestion and transplant dysfunction to decrease cardiac output with severe hemodynamic disturbances. Twenty patients showed various degrees of immediate amelioration of their condition. In contrast, there was no improvement in 3 cases who died of sepsis in the immediate postoperative period. Their Table 1. Indications for OLT Diagnosis
No.
BVH CVH Alcoholic HCC Retransplantation Caroli Polycysts Budd-Chiari Autoimmune Sclerosing cholangitis
1 1 6 2 5 2 2 1 1 1
Table 2. Complications Related to Caval Anastomosis Acute Problems
Cardiac output decrease Anastomotic torsion Congestion Congestion and cardiac output decrease Perioperative deaths Caval stenosis, acute Late problems Stenosis Late deaths
2 Veins Patch n⫽7
3 Veins Patch n ⫽ 10
Others n⫽3
n⫽2 n⫽3 n⫽2 n⫽1
n⫽2 n⫽1 n⫽4 n⫽4
n⫽1 n⫽0 n⫽1 n⫽0
n ⫽ 1* 0
n ⫽ 3† 0
n⫽3 1 case
None n ⫽ 1§
n ⫽ 3‡ n ⫽ 1§
None None
*Mesenteric bypass. † 1, cholangitis by candida; 2, sepsis; and 3, masive hemorrhage. ‡ Succesful angioplasty. § Viral relapse.
manifestations of graft congestion and hemodynamic disturbances were probably explained by their shock status, rather than a specific problem with venous drainage. There were 2 more deaths during the first 48 hours; they were caused by a celiac trunk pseudoaneurysm causing massive hemorrhage and an acute thrombosis of a messentericportal shunt, respectively. Four patients developed cavae stenosis: 1 early and 3 late. Its manifestations varied from persistent perioperative ascites to inferior vena caval obstruction or symptoms of Budd-Chiari syndrome. We succesfully treated all of them with angioplasty and balloon dilatation. Late hepatic vein obstruction is a rare complication, affecting less than 3% of OLT patients. Endovascular treatment for late hepatic venous obstruction has been proven effective and safe.8,9 In conclusion, we believe that adding a second caval anastomosis could be considered for patients with perioperative venous outflow obstruction. If there is a late stenosis, endovascular treatment is preferable.
REFERENCES 1. Parrilla P, Sánchez Bueno F, Figueras J, et al: Analysis of the complications of the piggy back technique in 1112 liver transplants. Transplantation 67:1214, 1999 2. Tzakis A, Todo, S, Starzl T: Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg 210:649, 1989 3. Busque S, Esquivel C, Concepcion W, et al: Experience with the piggyback technique without caval occlusion in adult orthotopic liver transplantation. Transplantation 65:77, 1998 4. Siu Man S, Chun Ho S, Fung Yee J, et al: Hepatic venous outflow obstruction after piggyback liver transplantation by an anusual mechanism: report of a case. World J Gastroenterol 12:5416, 2006 5. Min Wu Y, Voight M, Rayhill S, et al: Suprahepatic venacavaplasty (cavaplasty) with retrohepatic cava extension in liver transplantation: experience with first 115 cases. Transplantation 72:1389, 2001
2452 6. Navarro F, Moine MC, Fabre JM, et al: Specific vascular complications of orthotopic liver transplantation with preservation of the retrohepatic vena cava, review of 1361 cases. Transplantation 68:646, 1999 7. Aucejo F, Winans CH, Henderson, et al: Isolated right hepatic vein obstruction after piggyback liver transplantation. Liver Transpl 808, 2006
QUINTELA, FERNÁNDEZ, AGUIRREZABALAGA ET AL 8. Brostoff J, Bhati CH, Syn W: Late venous outflow obstruction after liver transplant: the “piggyback” syndrome. Eur J Int Med 374, 2008 9. Wang S, Sze D, Busque S, et al: Treatment of hepatic venous outflow obstruction after piggyback liver transplantation. Radiology 236:352, 2005
RESULTS
the others had a patch constructed with 3 veins. The incidence of obstructive problems was 3.9% and 2.7%, respectively. Eight patients showed a decrease in the cardiac output, not related to reperfusion syndrome. We attribute this hemodynamic disturbance to inadequate graft size that compressed the caval anastomosis. One patient suffered a major caval tear that disabled the use of a suprahepatic patch; another patient suffered a stenosis of the cava, anatomic abnormalities of the retrohepatic vena cava. In both cases it was necessary to perform a wider anastomosis to guarantee venous outflow. All of the patients underwent an additional cavo-caval anastomosis connecting the infrahepatic caval end from the graft to the recipient caval trunk, in an end-to-side manner for 21 patients during transplantation and for 2 patients in the immediate postoperative time. In 1 case a “neo-bed”
Twenty-three grafts performed in 22 patients underwent an extra cavo-caval anastomosis. Indications for OLT in these patients are presented in Table 1. The distribution of these vena cavae complications is shown in Table 2. The incidence of acute occlusive venous return was 3.41% (23/673). A patch was made in the recipient cava by joining the middle and left hepatic veins in 7 patients, and
From the Departments of General Surgery (J.Q., C.F., J.A., C.G., M.G.), Interventional Radiology (M.M.), and Gastroenterology and Hepatology (F.S.), Hospital Juan Canalejo, A Coruña, Spain. Address reprint requests to Julia Quintela Fandiño, Cirugı´a General A, CHU Juan Canalejo Xubias de arriba, n° 84, 15006, A Coruña, Spain. E-mail: [email protected]
LL the orthotopic liver transplantations (OLT) performed in our center were performed using the “piggyback” technique (PB). Even though complications related to retrocaval dissection were reduced, specific problems were related to this technique, especially involving liver venous outflow obstruction.1 The objectives of this study were to describe, and analyze the treatment and the clinical courses of cases in which outflow obstruction was related to the PB.
A
MATERIALS Our retrospective study was based on data from 673 OLT performed in our hospital between 1994 and 2008. We systematically performed a cavo-caval anastomosis using the PB technique. We performed an end-to-side cavo-caval anastomosis in addition to the pre-existent connection in cases with acute venous return occlusion.
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.06.066
© 2009 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
2450
Transplantation Proceedings, 41, 2450 –2452 (2009)
CAVO-CAVOSTOMY
2451
was achieved by suturing Gerota’s capsule to the diaphragm. In 1 case we performed reconstruction of the falciform ligament. Twenty patients experienced an immediate improvement of hemodynamic condition or of graft congestion. One patient developed persistent ascites in the postoperative period. A cavography showed stenosis of the anastomosis, which was successfully treated using angioplasty. Three more patients developed late caval stenosis at 6 months, 1 year, or 2 years later, respectively. There were 5 deaths in the immediate postoperative period due to: sepsis (n ⫽ 3), massive thrombosis of a mesenteric-portal bypass with ischemic hepatitis of the graft (n ⫽ 1), and a massive hemorrhage due to spontaneous tear of a pseudoaneurysm of the celiac trunk (n ⫽ 1). Two more patients died at 7 and 45 months, respectively, both due to viral relapse. The other 15 subjects are well.
DISCUSSION
The PB technique has been used since it was described by Tzakis et al in 1989,2 because of its advantages compared with the caval-interposition technique. Not only does it avoid retrocaval blunt dissection reducing blood loss, but also it helps to maintain hemodynamic stability in the recipient due to the partial cavae clamping, making retransplantation easier.3 Specific complications are poorly described in the literature. Budd-Chiari and congestion of the graft are the most frequent perioperative and early postoperative complications.1,4 Several techniques have been described to improve graft venous outflow: elongation of the caval anastomosis by performing a cavaplasty, omentoplasy, rotation of the graft, or performing a second caval anastamosis.1,5–7 We systematically decided to add a second caval anastomosis in all cases that showed any degree of venous outflow obstruction. These problems may vary from simple rotation of the graft and twisting of the anastomosis with congestion and transplant dysfunction to decrease cardiac output with severe hemodynamic disturbances. Twenty patients showed various degrees of immediate amelioration of their condition. In contrast, there was no improvement in 3 cases who died of sepsis in the immediate postoperative period. Their Table 1. Indications for OLT Diagnosis
No.
BVH CVH Alcoholic HCC Retransplantation Caroli Polycysts Budd-Chiari Autoimmune Sclerosing cholangitis
1 1 6 2 5 2 2 1 1 1
Table 2. Complications Related to Caval Anastomosis Acute Problems
Cardiac output decrease Anastomotic torsion Congestion Congestion and cardiac output decrease Perioperative deaths Caval stenosis, acute Late problems Stenosis Late deaths
2 Veins Patch n⫽7
3 Veins Patch n ⫽ 10
Others n⫽3
n⫽2 n⫽3 n⫽2 n⫽1
n⫽2 n⫽1 n⫽4 n⫽4
n⫽1 n⫽0 n⫽1 n⫽0
n ⫽ 1* 0
n ⫽ 3† 0
n⫽3 1 case
None n ⫽ 1§
n ⫽ 3‡ n ⫽ 1§
None None
*Mesenteric bypass. † 1, cholangitis by candida; 2, sepsis; and 3, masive hemorrhage. ‡ Succesful angioplasty. § Viral relapse.
manifestations of graft congestion and hemodynamic disturbances were probably explained by their shock status, rather than a specific problem with venous drainage. There were 2 more deaths during the first 48 hours; they were caused by a celiac trunk pseudoaneurysm causing massive hemorrhage and an acute thrombosis of a messentericportal shunt, respectively. Four patients developed cavae stenosis: 1 early and 3 late. Its manifestations varied from persistent perioperative ascites to inferior vena caval obstruction or symptoms of Budd-Chiari syndrome. We succesfully treated all of them with angioplasty and balloon dilatation. Late hepatic vein obstruction is a rare complication, affecting less than 3% of OLT patients. Endovascular treatment for late hepatic venous obstruction has been proven effective and safe.8,9 In conclusion, we believe that adding a second caval anastomosis could be considered for patients with perioperative venous outflow obstruction. If there is a late stenosis, endovascular treatment is preferable.
REFERENCES 1. Parrilla P, Sánchez Bueno F, Figueras J, et al: Analysis of the complications of the piggy back technique in 1112 liver transplants. Transplantation 67:1214, 1999 2. Tzakis A, Todo, S, Starzl T: Orthotopic liver transplantation with preservation of the inferior vena cava. Ann Surg 210:649, 1989 3. Busque S, Esquivel C, Concepcion W, et al: Experience with the piggyback technique without caval occlusion in adult orthotopic liver transplantation. Transplantation 65:77, 1998 4. Siu Man S, Chun Ho S, Fung Yee J, et al: Hepatic venous outflow obstruction after piggyback liver transplantation by an anusual mechanism: report of a case. World J Gastroenterol 12:5416, 2006 5. Min Wu Y, Voight M, Rayhill S, et al: Suprahepatic venacavaplasty (cavaplasty) with retrohepatic cava extension in liver transplantation: experience with first 115 cases. Transplantation 72:1389, 2001
2452 6. Navarro F, Moine MC, Fabre JM, et al: Specific vascular complications of orthotopic liver transplantation with preservation of the retrohepatic vena cava, review of 1361 cases. Transplantation 68:646, 1999 7. Aucejo F, Winans CH, Henderson, et al: Isolated right hepatic vein obstruction after piggyback liver transplantation. Liver Transpl 808, 2006
QUINTELA, FERNÁNDEZ, AGUIRREZABALAGA ET AL 8. Brostoff J, Bhati CH, Syn W: Late venous outflow obstruction after liver transplant: the “piggyback” syndrome. Eur J Int Med 374, 2008 9. Wang S, Sze D, Busque S, et al: Treatment of hepatic venous outflow obstruction after piggyback liver transplantation. Radiology 236:352, 2005