Liver transplantation in patients with portal vein thrombosis: A strategic road map throughout management.
Adult
Allografts
/ blood supply
Anastomosis, Surgical
/ adverse effects
Anticoagulants
/ therapeutic use
Blood Loss, Surgical
/ prevention & control
Clinical Decision-Making
/ methods
Decision Support Techniques
Female
Follow-Up Studies
Graft Survival
Humans
Kaplan-Meier Estimate
Liver
/ blood supply
Liver Cirrhosis
/ complications
Liver Transplantation
/ adverse effects
Male
Middle Aged
Portal Vein
/ pathology
Retrospective Studies
Severity of Illness Index
Thrombectomy
/ adverse effects
Treatment Outcome
Vascular Grafting
/ adverse effects
Venous Thrombosis
/ complications
Journal
Surgery
ISSN: 1532-7361
Titre abrégé: Surgery
Pays: United States
ID NLM: 0417347
Informations de publication
Date de publication:
12 2020
12 2020
Historique:
received:
12
05
2020
revised:
06
07
2020
accepted:
20
07
2020
pubmed:
31
8
2020
medline:
18
2
2021
entrez:
31
8
2020
Statut:
ppublish
Résumé
Liver transplantation in the setting of portal vein thrombosis is an intricate issue that occasionally necessitates extraordinary procedures for portal flow restoration. However, to date, there is no consensus on a persistent management strategy, particularly with extensive forms. This work aims to introduce our experience-based surgical management algorithm for portal vein thrombosis during liver transplantation and to clarify some of the debatable circumstances associated with this problematic issue. Between 2006 and 2019, 494 adults underwent liver transplantation at our institute. Ninety patients had preoperative portal vein thrombosis, and 79 patients underwent living donor liver transplantation. Our algorithm trichotomized the management plan into 3 pathways based on portal vein thrombosis grade. The surgical procedures implemented included thrombectomy, interposition vein grafts, jump grafts from the superior mesenteric vein, jump grafts from a collateral and renoportal anastomosis in 56, 13, 11, 4, and 2 patients, respectively. Four patients with mural thrombi did not require any special intervention. Thirteen patients experienced posttransplant portal vein complications. They all proved to have a patent portal vein by the end of follow-up regardless of the management modality. No significant survival difference was observed between cohorts with versus without portal vein thrombosis. The early graft loss rate was significantly higher with advanced grades (P = .048) as well as technically demanding procedures (P = .032). A stepwise broad-minded strategy should always be adopted when approaching advanced portal vein thrombosis during liver transplantation. An industrious preoperative evaluation should always be carried out to locate the ideal reliable source for portal flow restoration.
Sections du résumé
BACKGROUND
Liver transplantation in the setting of portal vein thrombosis is an intricate issue that occasionally necessitates extraordinary procedures for portal flow restoration. However, to date, there is no consensus on a persistent management strategy, particularly with extensive forms. This work aims to introduce our experience-based surgical management algorithm for portal vein thrombosis during liver transplantation and to clarify some of the debatable circumstances associated with this problematic issue.
METHODS
Between 2006 and 2019, 494 adults underwent liver transplantation at our institute. Ninety patients had preoperative portal vein thrombosis, and 79 patients underwent living donor liver transplantation. Our algorithm trichotomized the management plan into 3 pathways based on portal vein thrombosis grade. The surgical procedures implemented included thrombectomy, interposition vein grafts, jump grafts from the superior mesenteric vein, jump grafts from a collateral and renoportal anastomosis in 56, 13, 11, 4, and 2 patients, respectively. Four patients with mural thrombi did not require any special intervention.
RESULTS
Thirteen patients experienced posttransplant portal vein complications. They all proved to have a patent portal vein by the end of follow-up regardless of the management modality. No significant survival difference was observed between cohorts with versus without portal vein thrombosis. The early graft loss rate was significantly higher with advanced grades (P = .048) as well as technically demanding procedures (P = .032).
CONCLUSION
A stepwise broad-minded strategy should always be adopted when approaching advanced portal vein thrombosis during liver transplantation. An industrious preoperative evaluation should always be carried out to locate the ideal reliable source for portal flow restoration.
Identifiants
pubmed: 32861438
pii: S0039-6060(20)30467-0
doi: 10.1016/j.surg.2020.07.023
pii:
doi:
Substances chimiques
Anticoagulants
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1160-1168Informations de copyright
Copyright © 2020 Elsevier Inc. All rights reserved.