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Surgical text for orthotopic liver transplantation model with small-for-size graft in the pig: key techniques and pitfalls.

Hori T, Yagi S, Iida T, Taniguchi K, Yamamoto C, Sakakura R, Nakamura K, Uryuhara K, Oike F, Uemto S - Ann Gastroenterol (2012)

Bottom Line: The recipient suprahepatic inferior vena cava is clamped at the intramediastinal level, including the margins of the diaphragm in the clamp.Although survival rate during first forty cases were under 0.2, a reasonable survival rate of 0.6 had been achieved after the experiences of forty cases.Hepatic venous reconstruction should be completed without any outflow block, by using venous plasty and adequate clamping.

View Article: PubMed Central - PubMed

Affiliation: Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan (Tomohide Hori, Shintaro Yagi, Taku Iida, Kenji Uryuhara, Fumitaka Oike, Shinji Uemto).

ABSTRACT

Background: Challenges with small-for-size grafts are a critical issue in the liver transplantation field, and a reliable and reproducible animal model is required.

Method: We performed 50 orthotopic liver transplantations in pigs with a 30% graft, and retrospectively investigated the learning curves. We modified our surgical procedures according to our experience. Here, we describe our current procedures in detail with retrospective evaluation of our experience. The artery to the right lateral lobe crosses the portal vein trunk. A 30% graft is taken using the right lateral lobe attached to a sufficient length of aorta. Hepatic venous plasty is undertaken on the back table to attach a venous patch to the anterior wall of the suprahepatic inferior vena cava, which has no extrahepatic margin. To minimize hypoperfusion to the digestive tract, an aorta-to-aorta anastomosis is performed in a side-to-end fashion in a minimal surgical field before suprahepatic inferior vena cava and portal vein reconstruction. A temporary transjugular portosystemic shunt is also inserted before suprahepatic inferior vena cava reconstruction. The recipient suprahepatic inferior vena cava is clamped at the intramediastinal level, including the margins of the diaphragm in the clamp.

Results: Although survival rate during first forty cases were under 0.2, a reasonable survival rate of 0.6 had been achieved after the experiences of forty cases.

Conclusion: Precedent arterial reconstruction using an aorta-to-aorta anastomosis minimizes congestive damage and shortens operative time. Hepatic venous reconstruction should be completed without any outflow block, by using venous plasty and adequate clamping.

No MeSH data available.


Related in: MedlinePlus

(A) An adequate surgical field (blue arrow) is easily achieved using optimal retraction of the digestive tract (yellow arrow). (B) Retraction sometimes results in hypoperfusion and congestion of the shifted organs (circle). (C) A side-to-end anastomosis is performed between the aortas in a minimal surgical field using flexible retractors. (D) Stay sutures are placed bilaterally
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Figure 12: (A) An adequate surgical field (blue arrow) is easily achieved using optimal retraction of the digestive tract (yellow arrow). (B) Retraction sometimes results in hypoperfusion and congestion of the shifted organs (circle). (C) A side-to-end anastomosis is performed between the aortas in a minimal surgical field using flexible retractors. (D) Stay sutures are placed bilaterally

Mentions: An adequate surgical field is easily achieved by retracting the digestive tract (Fig. 12A). This retraction sometimes causes congestion and inadequate perfusion in the retracted organs (Fig. 12B). In the recipient operation, surgeons intensively take care of all organs, to ensure survival. To avoid hypoperfusion to the digestive tract, an aorta-to-aorta anastomosis is performed in a side-to-end fashion in the minimal surgical field available when using flexible retractors (Fig. 12C). The recipient aorta is partially dissected without injuring the para-aortic lymphatic duct, and partially clamped. An opening is made in the anterior wall of the recipient aorta and stay sutures are placed bilaterally (Fig. 12D). An aorta-to-aorta anastomosis is performed in a side-to-end fashion using a continuous suture (5-0 MPS) (Fig. 13A). This procedure maintains perfusion to the digestive tract (Fig. 13B), and drastically shortens the operative time compared with the microsurgical procedures required for hepatic artery reconstruction. After clamping of the graft aorta, the partial clamp on the recipient aorta is released.


Surgical text for orthotopic liver transplantation model with small-for-size graft in the pig: key techniques and pitfalls.

Hori T, Yagi S, Iida T, Taniguchi K, Yamamoto C, Sakakura R, Nakamura K, Uryuhara K, Oike F, Uemto S - Ann Gastroenterol (2012)

(A) An adequate surgical field (blue arrow) is easily achieved using optimal retraction of the digestive tract (yellow arrow). (B) Retraction sometimes results in hypoperfusion and congestion of the shifted organs (circle). (C) A side-to-end anastomosis is performed between the aortas in a minimal surgical field using flexible retractors. (D) Stay sutures are placed bilaterally
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3959390&req=5

Figure 12: (A) An adequate surgical field (blue arrow) is easily achieved using optimal retraction of the digestive tract (yellow arrow). (B) Retraction sometimes results in hypoperfusion and congestion of the shifted organs (circle). (C) A side-to-end anastomosis is performed between the aortas in a minimal surgical field using flexible retractors. (D) Stay sutures are placed bilaterally
Mentions: An adequate surgical field is easily achieved by retracting the digestive tract (Fig. 12A). This retraction sometimes causes congestion and inadequate perfusion in the retracted organs (Fig. 12B). In the recipient operation, surgeons intensively take care of all organs, to ensure survival. To avoid hypoperfusion to the digestive tract, an aorta-to-aorta anastomosis is performed in a side-to-end fashion in the minimal surgical field available when using flexible retractors (Fig. 12C). The recipient aorta is partially dissected without injuring the para-aortic lymphatic duct, and partially clamped. An opening is made in the anterior wall of the recipient aorta and stay sutures are placed bilaterally (Fig. 12D). An aorta-to-aorta anastomosis is performed in a side-to-end fashion using a continuous suture (5-0 MPS) (Fig. 13A). This procedure maintains perfusion to the digestive tract (Fig. 13B), and drastically shortens the operative time compared with the microsurgical procedures required for hepatic artery reconstruction. After clamping of the graft aorta, the partial clamp on the recipient aorta is released.

Bottom Line: The recipient suprahepatic inferior vena cava is clamped at the intramediastinal level, including the margins of the diaphragm in the clamp.Although survival rate during first forty cases were under 0.2, a reasonable survival rate of 0.6 had been achieved after the experiences of forty cases.Hepatic venous reconstruction should be completed without any outflow block, by using venous plasty and adequate clamping.

View Article: PubMed Central - PubMed

Affiliation: Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan (Tomohide Hori, Shintaro Yagi, Taku Iida, Kenji Uryuhara, Fumitaka Oike, Shinji Uemto).

ABSTRACT

Background: Challenges with small-for-size grafts are a critical issue in the liver transplantation field, and a reliable and reproducible animal model is required.

Method: We performed 50 orthotopic liver transplantations in pigs with a 30% graft, and retrospectively investigated the learning curves. We modified our surgical procedures according to our experience. Here, we describe our current procedures in detail with retrospective evaluation of our experience. The artery to the right lateral lobe crosses the portal vein trunk. A 30% graft is taken using the right lateral lobe attached to a sufficient length of aorta. Hepatic venous plasty is undertaken on the back table to attach a venous patch to the anterior wall of the suprahepatic inferior vena cava, which has no extrahepatic margin. To minimize hypoperfusion to the digestive tract, an aorta-to-aorta anastomosis is performed in a side-to-end fashion in a minimal surgical field before suprahepatic inferior vena cava and portal vein reconstruction. A temporary transjugular portosystemic shunt is also inserted before suprahepatic inferior vena cava reconstruction. The recipient suprahepatic inferior vena cava is clamped at the intramediastinal level, including the margins of the diaphragm in the clamp.

Results: Although survival rate during first forty cases were under 0.2, a reasonable survival rate of 0.6 had been achieved after the experiences of forty cases.

Conclusion: Precedent arterial reconstruction using an aorta-to-aorta anastomosis minimizes congestive damage and shortens operative time. Hepatic venous reconstruction should be completed without any outflow block, by using venous plasty and adequate clamping.

No MeSH data available.


Related in: MedlinePlus