Portal vein blood flow is very important for the normal function of transplanted liver. The author reviewed the management methods of different portal vein thrombosis classification in the liver transplantation (LT). The prognosis of LT in the patients with Yerdel 1–3 thrombosis is similar to that the patients without thrombosis. The portal vein reconstruction of the patients with Yerdel 4 thrombosis can be realized by varicose vein to portal anastomosis, renoportal anastomosis or cavoportal hemitransposition. When anastomosis is made at the proximal side of a spontaneous shunt between the portal and cava system, the blood shunted from portal system can be reintroduced into the donor liver, which is crucial for the management of Yerdel 4 thrombosis. The establishments of artificial shunt by distal splenic vein, mesenteric vein or “multiple to one” anastomosis are effective attempts to drain the blood from portal system to the donor liver. For more severe diffuse thrombosis of portal vein system, multivisceral transplantation, including liver and small intestine, should be considered. The cases of LT in the patients with complex portal vein thrombosis are increasing, however the prognosis remains to be determined after accumulation of the cases.
ObjectivesTo assess the quality of clinical practice guidelines for transplantation in 2017. MethodsPubMed, NICE, NGC, NCCN, SIGN, CMA Infobase and GIN databases were searched online to collect guidelines for transplantation published in 2017. Guidelines were then assessed by using the AGREE Ⅱ instrument. ResultsA total of 10 guidelines were included. The result of assessments by the AGREE Ⅱ instrument showed a clear discrepancy among domains (P=0.001). Satisfactory scores were found in domains of " scope and purpose”, " clarity of presentation” and " overall score”, where the average scores were 90.8% (95%CI 83.5% to 98.1%), 82.5% (95%CI 72.7% to 92.3%) and 75.6% (95%CI 66.6% to 84.6%), respectively. Low scores were found in domains of " stakeholder involvement” and " applicability”, in which a score of 40.0% (95%CI 32.4% to 47.6%) and a score of 27.8% (95%CI 11.2% to 44.5%) were achieved, respectively. ConclusionsThere is a clear discrepancy among domains of global clinical practice guidelines for transplantation in 2017. Guidelines in this field should be improved in " stakeholder involvement” and " applicability”.
Objective To analyze the effect of monitoring and modulating the portal vein pressure and blood flow during living donor liver transplantation （LDLT） on preventing small-for-size-syndrome (SFSS). Methods Data of forty-four LDLT recipients between Oct.2007 and Oct.2008 were reviewed. Actual graft-to-recipient weight ratio（GRWR）, portal vein flow and pressure during operation and syndrome of SFSS after operation were recorded. The patients received splenectomy or splenic artery ligation according to actual GRWR, portal vein flow and pressure and WBC. Relationships between patients’ GRWR, portal vein flow, portal vein pressure and occurrence of SFSS were analyzed. Results Six patients received splenectomy and 7 patients received splenic artery ligation to decrease the portal vein flow and pressure during the operation. The portal vein flow and pressure decreased after splenectomy （Plt;0.05）. The portal vein pressure decreased （Plt;0.05） and the portal vein flow had no significant change after splenic artery ligation （P＞0.05）. No SFSS occurred after operation. Conclusion Modulation of portal vein flow and pressure by splenectomy or splenic artery ligation during LDLT operation can decrease the portal vein flow and pressure, and which can prevent the incidence of SFSS.
Objective To observe the recovery of recipients with complex portal vein thrombosis (CPVT) underwent “multiple to one” anastomosis and patency of portal vein blood flow during liver transplantation, and to ensure the reliability of this method. MethodsThe clinicopathologic data of the recipients with CPVT underwent “multiple to one” anastomosis in the Beijing Friendship Hospital, Capital Medical University were collected retrospectively. The “multiple to one” portal vein reconstruction was defined as the anastomosis of multiple vessels of portal venous system with the portal vein of graft, or the anastomosis that connected the blood vessel of portal venous system and the left renal vein/inferior vena cava to the portal vein of graft. ResultsA total of 5 patients were collected, including 1 patient with Yerdel grade 3 thrombosis and 4 patients with Yerdel grade 4 thrombosis. In 3 cases, the left renal vein, inferior vena cava, left renal vein were combined with the parabiliary vein, respectively, in the anastomosis to the donor portal vein. In another 2 cases, portal vein and left renal vein were combined with gastric coronary vein, respectively, in the anastomosis to the donor portal vein. During the follow-up period of 162–865 d, all patients had the stable portal vein blood flow without any symptom of portal hypertension. One patient had thrombosis at the anastomosis with varicose vein, while the anastomosis with left renal vein was unobstructed, which did not affect the donor liver function. ConclusionMultiple blood supply of portal vein is established after “multiple to one” anastomosis, and stability of portal vein blood flow can be maintained after a blood redistribution of portal venous system following liver transplantation.
Objective To explore the causes and prognosis of liver retransplantation. Methods The clinical data of 215 cases who had underwent liver retransplantation in Tianjin First Central Hospital between Nov. 26th 2003 and May. 26th 2012 were analyzed retrospectively for its causes and prognosis. Results Two hundreds and fifteen cases were enrolled， including 200 cases of 2 times liver transplantation， 14 cases of 3 times liver transplantation， and 1 case of 4 times liver transplantation. The major causes of the second liver transplantation were biliary complication （53.5%， 115/215） and primary non-function or dysfunction of liver graft （8.4%， 18/215）， and the major causes of the third liver transplantation were biliary complication （5/14） and hepatocellular carcinoma recurrence （2/14）. The liver graft survival rate of late liver retransplantation （at least 1 month after operation） was significantly higher than that of early liver retrans-plantation （less than 1 month after operation） for the second liver transplantation （P=0.005）. The liver graft survival rate of the second liver transplantation was significantly higher than that of the third liver transplantation （P=0.043）. Compared with biliary complication， cases of hepatocellular carcinoma recurrence （P=0.001） and primary non-function or dysfunction of liver graft （P=0.033） had lower graft survival rates， while cases of chronic failure of liver graft had a higher survival rate （P=0.037）. Conclusions Biliary complication is the main cause of liver retransplantation. The liver retransplantations which are performed less than 1 month after prior liver transplantation result in a relative low survival rate in reason of the increase of perioperative death. The prognosis of liver retransplantation for hepatocellular carcinoma recurrence is unacceptable， while cases of chronic failure of liver graft have optimal prognosis.
Objective To discuss the criteria of recipient selection，surgical approach，and complications and its theray by using of pediatric donation after cardiac death liver graft in adult recipient. Methods The clinical data of one case of pediatric donation after cardiac death liver to adult recipient was analyzed retrospectively and the literatures were reviewed. Results A 6-year-old girl pronounced brain death due to drowning and on the basis of cardiopulmonary criteria donated the organ．The liver graft weight was 598 g and the warm ischemic time was 10 min. The liver donor was transplanted to a 64-year-old woman，the graft to recipient weight ratio was 1.09%，the graft volume/estimated standard liver volume was 61.8%．The classic orthotopic liver transplantation without bypass was underwent，the postoperative recovery was smooth after the liver transplantation．The CT scan showed that the liver graft volume was 1 003cm3 on day 14 after operation．The patient was discharged on 45 d after orthotopic liver transplantation and the liver function was normal when followed-up 3 months after the operation. Conclusions Pediatric donation after cardiac death liver graft can be successfully utilized to adult recipient．Recipient selection and surgical approach should be decided by conditions of both donor and graft．