- Email: [email protected]
Hepatic Resection After Liver Transplantation as a Graft-Saving Procedure
Hepatic Resection After Liver Transplantation as a Graft-Saving Procedure J.F. Guerra, N. Jarufe, and J. Martı´nez ABSTRACT Biliary lesions and hepatic artery thrombosis are known causes of posttransplant liver failure and liver retransplantation. The shortage of organs and the results of retransplantation have forced transplant teams to developed graft-saving techniques. We report two cases who underwent hepatic resection after liver transplantation. In both cases, a left lateral segmentectomy was performed. At follow-up, the patients are well with optimal graft function. We believe this kind of resection represents an adequate alternative in selected cases and must be considered before enlistment for retransplantation. EPATIC RESECTIONS have been used as graftsaving procedures in liver transplant recipients.1,2 Few cases have been reported; the main indications include ischemic-type biliary lesions and segmental hepatic artery thrombosis, but the procedure can also be performed for recurrent hepatocellular carcinoma, liver trauma, or liver infections.3–5 Most of the time, these patients are referred for liver retransplantation;6,7 however, considering the organ shortage,8 liver resections may be a good approach. Herein we have reported two patients who required an hepatic resection as a graft-saving procedure after liver transplantation (OLT).
H
CASE REPORTS Case 1 A 54-year-old man underwent OLT for hemochromatosis after a 522-minute cold ischemia time. We performed a duct-to-duct biliary anastomosis. He developed an early postransplant bile leak and biloma. Initially, a percutaneous drain was placed; the biliary fistula was well tolerated. The hepatic artery was normal (Fig 1). After persistent high bile flow through the drain, a surgical hepaticojejunostomy was planned. The bilioenteric anastomosis was performed high up on the hilar plate, because the extrahepatic bile duct was totally necrotic. No morbidity was evident over the following 22 months, when the patient developed repeated episodes of cholangitis. Magnetic resonance cholangiogram (MRC) showed focal intrahepatic bile duct dilations in segments II and III (Fig 2). After unsuccessful percutaneous, transhepatic drainage and endoscopic procedures were attempted, we performed a left lateral segmentectomy. The postoperative period was uneventful. Twenty months later, the patient was readmitted with jaundice and fever. A new MRC confirmed perianastomotic stones with an intrahepatic (segment VI) bile duct dilation. An endoscopic attempt was unsuccessful due to the length of the Roux-en-Y loop,
pending it unable to reach the anastomotic area. Therefore, we performed an open transanastomotic hepatolithotomy. The patency of the segment VI duct was confirmed with a cholangioscope. At long-term follow-up, the patient is asymptomatic with normal liver function tests.
Case 2 A 60-year-old male patient with decompensated nonalcoholic steatohepatitis underwent OLT. The cold ischemia time was 436 minutes. We performed a duct-to-duct biliary anastomosis. During the postoperative period, a bile leak was endoscopically treated. Six weeks after OLT, a segmental arterial thrombosis was evident with a left lateral segment necrosis and abscess formation (Fig 3). We performed a left lateral segmentectomy. The patient had an uneventful recovery. One year after the hepatic resection, he remains asymptomatic with normal graft function.
DISCUSSION
A few cases of hepatic resections ranging from segmentectomies to extended hepatectomies have been reported as graft-saving procedures after liver transplantation.1–5 As mentioned by Guckelberger et al,4 setting a division line at the third month after OLT, resections may have been performed in an early period (related to ischemic necrosis or abscess formation) or in a late period (related to nonanastomotic biliary strictures). Our patients underwent one each, early and late resection, with similar indications as those previously reported.1–5 From the Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile. Address reprint requests to Juan Francisco Guerra, Marcoleta 367, Santiago, Chile. E-mail: [email protected]
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.01.078
© 2009 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1994
Transplantation Proceedings, 41, 1994 –1996 (2009)
HEPATIC RESECTION AFTER OLT
Fig 1. Computed tomographic angiogram: case 1.
In our first case, we believe that an early postoperative bile leak and biloma with a subsequent abscess and extrahepatic bile duct necrosis were the starting points for the patient’s problems. Considering that the hepatic artery was patent by Doppler ultrasound and computed tomography angiogram, the bile duct necrosis may be explained by a poorly drained biloma, infection, and chronic inflammation. Both endoscopic and interventional radiology procedures were not suscessful. Once
1995
Fig 3.
Ischemic abscess and peritoneal fluid: case 2.
the bilioenteric anastomosis was decided, an important issue was to perform it at the hilar plate, trying to obtain the most appropiate biliary drainage in healthy tissue. Nevertheless, at follow-up, focal intrahepatic bile duct abnormalities were evident. Our second case was a clear abscess formation due to ischemic necrosis due to thrombosis of the segmental hepatic artery. In both cases, hepatic resection was performed without Pringle’s manuver and with partial mobilization, to avoid additional ischemic injury in the transplanted graft. We believe that the strongly recommended technical tip in hepatic resection after transplantation is identification of the artery with minimal pedicle dissection. At followup, both patients are doing well, with optimal graft function. In many centers, these patients are considered for liver retransplantation, but due to organs shortage and the relatively poor results of liver retransplantation,6,7,9 a graftsaving procedure such as liver resection, in selected cases represents an alternative with low morbidity.
REFERENCES
Fig 2. Segmental bile duct dilation: case 1.
1. Dousset B, Filipponi F, Soubrane O, et al: Partial hepatic resection for ischemic graft damage after liver transplantation. A graft saving option? Surgery 115:540, 1994 2. Filipponi F, Vistoli F, Urbani L, et al: Extended right hepatectomy as a graft-saving option in non-anastomotic biliary strictures after liver transplantation. Hepatogastroenterology 49: 1679, 2002 3. Catalano G, Urbani L, Biancofiore G, et al: Hepatic resection after liver transplantation as a graft-saving procedure: indication criteria, timing and outcome. Transplant Proc 36:545, 2004
1996 4. Guckelberger O, Stange B, Glanemann M, et al: Hepatic resection in liver transplants recipients: single center experience and review of the literature. Am J Transplant 5:2403, 2005 5. Honoré P, Detry O, Hamoir E, et al: Right hepatectomy as a liver graft-saving procedure. Liver Transpl 7:269, 2001 6. Wang ZF, Liu C: Liver retransplantation: Indications and outcomes. Hepatobiliary Pancreat Dis Int 3:175, 2004
GUERRA, JARUFE, AND MARTÍNEZ 7. Shen ZY, Zhu ZJ, Deng YL, et al: Liver retransplantation: report of 80 cases and review of literature. Hepatobiliary Pancreat Dis Int 5:180, 2006 8. Thalheimer U, Capra F: Liver transplantation: making the best out of what we have. Dig Dis Sci 47:945, 2002 9. Markmann JF, Markowitz JS, Yersiz H, et al: Long-term survival after retransplantation of the liver. Ann Surg 226:408, 1997
H
CASE REPORTS Case 1 A 54-year-old man underwent OLT for hemochromatosis after a 522-minute cold ischemia time. We performed a duct-to-duct biliary anastomosis. He developed an early postransplant bile leak and biloma. Initially, a percutaneous drain was placed; the biliary fistula was well tolerated. The hepatic artery was normal (Fig 1). After persistent high bile flow through the drain, a surgical hepaticojejunostomy was planned. The bilioenteric anastomosis was performed high up on the hilar plate, because the extrahepatic bile duct was totally necrotic. No morbidity was evident over the following 22 months, when the patient developed repeated episodes of cholangitis. Magnetic resonance cholangiogram (MRC) showed focal intrahepatic bile duct dilations in segments II and III (Fig 2). After unsuccessful percutaneous, transhepatic drainage and endoscopic procedures were attempted, we performed a left lateral segmentectomy. The postoperative period was uneventful. Twenty months later, the patient was readmitted with jaundice and fever. A new MRC confirmed perianastomotic stones with an intrahepatic (segment VI) bile duct dilation. An endoscopic attempt was unsuccessful due to the length of the Roux-en-Y loop,
pending it unable to reach the anastomotic area. Therefore, we performed an open transanastomotic hepatolithotomy. The patency of the segment VI duct was confirmed with a cholangioscope. At long-term follow-up, the patient is asymptomatic with normal liver function tests.
Case 2 A 60-year-old male patient with decompensated nonalcoholic steatohepatitis underwent OLT. The cold ischemia time was 436 minutes. We performed a duct-to-duct biliary anastomosis. During the postoperative period, a bile leak was endoscopically treated. Six weeks after OLT, a segmental arterial thrombosis was evident with a left lateral segment necrosis and abscess formation (Fig 3). We performed a left lateral segmentectomy. The patient had an uneventful recovery. One year after the hepatic resection, he remains asymptomatic with normal graft function.
DISCUSSION
A few cases of hepatic resections ranging from segmentectomies to extended hepatectomies have been reported as graft-saving procedures after liver transplantation.1–5 As mentioned by Guckelberger et al,4 setting a division line at the third month after OLT, resections may have been performed in an early period (related to ischemic necrosis or abscess formation) or in a late period (related to nonanastomotic biliary strictures). Our patients underwent one each, early and late resection, with similar indications as those previously reported.1–5 From the Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile. Address reprint requests to Juan Francisco Guerra, Marcoleta 367, Santiago, Chile. E-mail: [email protected]
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.01.078
© 2009 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1994
Transplantation Proceedings, 41, 1994 –1996 (2009)
HEPATIC RESECTION AFTER OLT
Fig 1. Computed tomographic angiogram: case 1.
In our first case, we believe that an early postoperative bile leak and biloma with a subsequent abscess and extrahepatic bile duct necrosis were the starting points for the patient’s problems. Considering that the hepatic artery was patent by Doppler ultrasound and computed tomography angiogram, the bile duct necrosis may be explained by a poorly drained biloma, infection, and chronic inflammation. Both endoscopic and interventional radiology procedures were not suscessful. Once
1995
Fig 3.
Ischemic abscess and peritoneal fluid: case 2.
the bilioenteric anastomosis was decided, an important issue was to perform it at the hilar plate, trying to obtain the most appropiate biliary drainage in healthy tissue. Nevertheless, at follow-up, focal intrahepatic bile duct abnormalities were evident. Our second case was a clear abscess formation due to ischemic necrosis due to thrombosis of the segmental hepatic artery. In both cases, hepatic resection was performed without Pringle’s manuver and with partial mobilization, to avoid additional ischemic injury in the transplanted graft. We believe that the strongly recommended technical tip in hepatic resection after transplantation is identification of the artery with minimal pedicle dissection. At followup, both patients are doing well, with optimal graft function. In many centers, these patients are considered for liver retransplantation, but due to organs shortage and the relatively poor results of liver retransplantation,6,7,9 a graftsaving procedure such as liver resection, in selected cases represents an alternative with low morbidity.
REFERENCES
Fig 2. Segmental bile duct dilation: case 1.
1. Dousset B, Filipponi F, Soubrane O, et al: Partial hepatic resection for ischemic graft damage after liver transplantation. A graft saving option? Surgery 115:540, 1994 2. Filipponi F, Vistoli F, Urbani L, et al: Extended right hepatectomy as a graft-saving option in non-anastomotic biliary strictures after liver transplantation. Hepatogastroenterology 49: 1679, 2002 3. Catalano G, Urbani L, Biancofiore G, et al: Hepatic resection after liver transplantation as a graft-saving procedure: indication criteria, timing and outcome. Transplant Proc 36:545, 2004
1996 4. Guckelberger O, Stange B, Glanemann M, et al: Hepatic resection in liver transplants recipients: single center experience and review of the literature. Am J Transplant 5:2403, 2005 5. Honoré P, Detry O, Hamoir E, et al: Right hepatectomy as a liver graft-saving procedure. Liver Transpl 7:269, 2001 6. Wang ZF, Liu C: Liver retransplantation: Indications and outcomes. Hepatobiliary Pancreat Dis Int 3:175, 2004
GUERRA, JARUFE, AND MARTÍNEZ 7. Shen ZY, Zhu ZJ, Deng YL, et al: Liver retransplantation: report of 80 cases and review of literature. Hepatobiliary Pancreat Dis Int 5:180, 2006 8. Thalheimer U, Capra F: Liver transplantation: making the best out of what we have. Dig Dis Sci 47:945, 2002 9. Markmann JF, Markowitz JS, Yersiz H, et al: Long-term survival after retransplantation of the liver. Ann Surg 226:408, 1997