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Porcine Liver Transplantation Without Veno-Venous Bypass As an Extended Criteria Donor Model
Published on: August 17, 2022
"Intrapericardial Approach" for Venous Outflow Reconstruction in Living-Donor Liver Transplantation for Budd-Chiari
Koichiro Hata1,2, Tetsuya Tajima1, Satoshi Ogiso1
1Department of Surgery, Graduate School of Medicine Kyoto University Kyoto Japan.
Insights
The novel Intrapericardial Approach (IPA) for living-donor liver transplantation (LDLT) in Budd-Chiari Syndrome (BCS) significantly reduces recurrence and improves survival by reconstructing hepatic venous outflow using only healthy vessels.
Area of Science:
- Hepatology
- Transplant Surgery
- Vascular Reconstruction
Background:
- Living-donor liver transplantation (LDLT) for Budd-Chiari Syndrome (BCS) faces challenges in hepatic venous (HV)-inferior vena cava (IVC) reconstruction due to diseased native vessels.
- BCS commonly involves the IVC in the Asia-Pacific region, necessitating innovative surgical techniques for HV-IVC reconstruction.
Purpose of the Study:
- To introduce and evaluate the efficacy of the novel "intrapericardial approach" (IPA) for HV-IVC reconstruction in LDLT for BCS.
- To compare the outcomes of IPA with conventional IVC-preserving techniques in BCS-LDLT patients.
Main Methods:
- The study details the IPA technique for HV-outflow tract reconstruction in four typical LDLT scenarios for BCS, utilizing only healthy vascular tissues.
- A retrospective comparison was made between 10 patients treated with IPA and 10 patients treated with conventional techniques (cavoplasty/patch-plasty) among 20 BCS-LDLT cases.
Main Results:
- The IPA technique was consistently applicable across all BCS-LDLT scenarios.
- IPA demonstrated significantly lower post-transplant BCS recurrence (p=0.04) compared to conventional methods.
- IPA was associated with improved relapse-free (p=0.02) and overall recipient survival (p=0.03), achieving 100% graft and patient survival at 10 years.
Conclusions:
- The Intrapericardial Approach (IPA) offers a novel and practical solution for challenging HV-IVC reconstruction in LDLT for BCS.
- IPA is associated with reduced post-transplant BCS recurrence and favorable short- and long-term outcomes, including high graft and patient survival rates.
Abstract:
Unlike deceased-donor liver transplantation, living-donor liver transplantation (LDLT) for Budd-Chiari Syndrome (BCS) presents distinctive challenges in hepatic venous (HV)-outflow reconstruction because diseased HV-inferior vena cava (IVC) cannot be entirely replaced with healthy donor vessels. In the Asia-Pacific region, where LDLT predominates, BCS frequently involves the hepatic IVC, thus requiring innovative surgical strategies for HV-IVC reconstruction. Here we introduce a novel series of surgical technique-"intrapericardial approach (IPA)"-which reconstructs HV-outflow tract in the pericardium using only healthy vascular tissues, thereby minimizing post-transplant BCS recurrence. Detailed procedures are illustrated for four typical LDLT scenarios, classified by graft-type (left- or right-lobe) and by the need for IVC reconstruction (acute or chronic BCS). A representative surgical video is also provided. Of our 2089 consecutive liver transplants, 20 patients underwent LDLT for BCS: 10 with conventional IVC-preserving techniques (cavoplasty and/or patch-plasty) and 10 using IPA. Across all four clinical scenarios aforementioned, the key concept of IPA-creating new HV-outflow with only healthy vessels-was consistently applicable. IPA was associated with significantly lower post-transplant BCS recurrence (p = 0.04) and improved both relapse-free and overall recipient survival (p = 0.02 and 0.03, respectively) compared to conventional techniques, yielding 100% graft and patient survival through 10 years. This report also highlights key considerations and pitfalls for pre-, intra-, and post-transplant management in BCS-LDLT. In conclusion, IPA appears to be associated with reduced post-transplant BCS recurrence and favorable short- and long-term outcomes, offering a novel practical solution for challenging HV-IVC reconstruction in BCS-LDLT.
