How to do liver transplantation using renoportal bypass

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Portal vein (PV) thrombosis is classified in four grades: grade 1, partial PV thrombosis (<50% of the lumen) with or without minimal extension into the superior mesenteric vein (SMV); grade 2, PV thrombosis, >50% occlusion, including total PV occlusion, with or without minimal extension into the SMV; grade 3, PV thrombosis, complete thrombosis of both PV and proximal SMV with open distal SMV; grade 4, PV thrombosis, complete thrombosis of PV and proximal and distal SMV.1
Clear‐cut criteria of choice for the best technique for PV reconstruction during liver transplantation (LT) in the setting of extensive portomesenteric thrombosis have not been established. No prior video documentation of renoportal bypass (RPB) was found in the medical literature or in the internet. The authors hereby illustrate this unusual technique with figures and video documentation (Figs S1–S3, Video S1).
The case of a 57‐year‐old male with hepatitis C virus infection, Child C cirrhosis (Model for End‐Stage Liver Disease score 38), grade 4 PV thrombosis is illustrated in this report. Extensive PV thrombosis and a large spontaneous splenorenal shunt had been documented on preoperative computed tomography (CT) angiogram.
During surgical exploration, the porta hepatis was dissected in a usual manner and the presence of grade 4 PV thrombosis was confirmed. The hepatic artery and the bile duct were doubly ligated and severed. Dissection of the retro‐hepatic inferior vena cava (IVC) with ligation of its tributaries from the liver was performed as a preparation for piggy‐back reconstruction. The right hepatic vein was stapled and cut, and the PV was ligated. The middle and left hepatic veins were clamped and severed, and the cirrhotic liver was removed.
Kocher manoeuvre and caudal mobilization of the duodenum and the head of the pancreas were performed. The soft tissues next to the anterior wall of the IVC were removed. The left renal vein (LRV) was doubly clamped next to the IVC, cut and sutured. Anastomosis of the middle and left hepatic veins to donor IVC was performed as usual using the piggy‐back technique.
A RPB was constructed using a segment of donor's femoral vein as an interposition graft between the LRV and PV of the liver allograft. The venous graft was sewn to the LRV remnant proximally and to the PV of the liver graft distally, both in an end‐to‐end fashion employing running 6–0 polydioxanone sutures (Fig. 1) (operative time = 480 min; cold ischaemia = 585 min; warm ischemia = 40min; blood loss = 3.7 L).
Daily Doppler ultrasound was performed during the first post‐operative week. Post‐transplant course of this patient was complicated by transient ascites and renal failure demanding transient dialysis. Patient was discharged home on post‐transplant day 47 with normal renal function. He is currently asymptomatic 6 months after LT. CT angiogram reveals a patent RPB.
Extensive PV thrombosis is a technical challenge to successful LT. Specifically for grade 3 PVT, whenever PV thromboendovenectomy is not accomplished, placement of an interposition venous graft between recipient SMV and PV of the liver allograft would be the first choice.
For grade 4 PVT, utilization of portomesenteric venous system of the recipient usually is not feasible. The same applies to grade 3 PVT in the presence of hypoplasic PV (or a PV with a low flow despite LRV ligation).2 In these settings, potential options include connecting PV of the liver graft to a collateral vein,3 construction of a RPB,4 cavoportal hemitransposition,5 PV arterialization and multivisceral transplantation.6
Pre‐transplant planning with CT angiogram documenting a large spontaneous splenorenal shunt is necessary for the performance of RPB. As for minimizing cold ischaemia in this setting, standard criteria local donors are preferred. LRV always should be ligated next to IVC.
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