Liver transplantation techniques: Difference between revisions
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==Overview== | ==Overview== | ||
Liver transplantation techniques includes left lobe transplantation, right lobe transplantation, split-liver transplantation, and marginal liver grafts. In left lobe technique, the left and [[Hepatic vein|middle hepatic veins]], [[Hepatic artery|left hepatic artery]], and left [[portal vein]] are dissected. Small portal vein branches are ligated. The left [[bile duct]] is divided. In right lobe technique, the right lobe fits correctly into the right subphrenic space, making the vascular anastomoses easier to perform. Right lobe grafts are prone to a variety of technical complications. After [[cholecystectomy]], [[Intraoperative monitoring|intraoperative ultrasound]] may be used to mark the position of the [[Hepatic vein|hepatic veins]] and portal branches. The right [[hepatic artery]] and right [[portal vein]] are dissected, followed by the retrohepatic [[Vena cavae|vena cava]], isolating the origin of the right hepatic vein. Marginal graft means grafts from a higher risk group of donors based on demographic, clinical, laboratory, and histological data. Marginal liver grafts donors include those with any of the following characteristics: Liver donor age >70 years, livers from [[hepatitis C]] positive donors, livers with cold [[ischemia]] time >12 hours, livers from donation after [[Sudden cardiac death|cardiac death]] donors, livers with >30 percent [[steatosis]], and livers split between two recipients. | |||
==Liver transplantation techniques== | ==Liver transplantation techniques== | ||
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* The right [[bile duct]] is isolated, completing mobilization of the right lobe.<ref name="pmid9846514">{{cite journal| author=Wachs ME, Bak TE, Karrer FM, Everson GT, Shrestha R, Trouillot TE et al.| title=Adult living donor liver transplantation using a right hepatic lobe. | journal=Transplantation | year= 1998 | volume= 66 | issue= 10 | pages= 1313-6 | pmid=9846514 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9846514 }}</ref> | * The right [[bile duct]] is isolated, completing mobilization of the right lobe.<ref name="pmid9846514">{{cite journal| author=Wachs ME, Bak TE, Karrer FM, Everson GT, Shrestha R, Trouillot TE et al.| title=Adult living donor liver transplantation using a right hepatic lobe. | journal=Transplantation | year= 1998 | volume= 66 | issue= 10 | pages= 1313-6 | pmid=9846514 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9846514 }}</ref> | ||
* The liver parenchyma is transected using an ultrasonic scalpel. | * The liver parenchyma is transected using an ultrasonic scalpel. | ||
* A portoportal anastomosis is then made between the donor right portal vein and the portal vein of the recipient. | * A portoportal [[anastomosis]] is then made between the donor right portal vein and the portal vein of the recipient. | ||
== Video shows right lobe transplantation steps == | == Video shows right lobe transplantation steps == | ||
{{#ev:youtube|iNEcmYFRbfY}} | {{#ev:youtube|iNEcmYFRbfY}} | ||
'''Split-liver transplantation''' | ==== '''Split-liver transplantation''' ==== | ||
* Splitting donor livers into left lateral and extended right grafts for transplantation into a pediatric and an adult recipient.<ref name="pmid12360426">{{cite journal| author=Emond JC, Freeman RB, Renz JF, Yersiz H, Rogiers X, Busuttil RW| title=Optimizing the use of donated cadaver livers: analysis and policy development to increase the application of split-liver transplantation. | journal=Liver Transpl | year= 2002 | volume= 8 | issue= 10 | pages= 863-72 | pmid=12360426 | doi=10.1053/jlts.2002.34639 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12360426 }}</ref> | * Splitting donor livers into left lateral and extended right grafts for transplantation into a pediatric and an adult recipient.<ref name="pmid12360426">{{cite journal| author=Emond JC, Freeman RB, Renz JF, Yersiz H, Rogiers X, Busuttil RW| title=Optimizing the use of donated cadaver livers: analysis and policy development to increase the application of split-liver transplantation. | journal=Liver Transpl | year= 2002 | volume= 8 | issue= 10 | pages= 863-72 | pmid=12360426 | doi=10.1053/jlts.2002.34639 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12360426 }}</ref> | ||
* Splitting livers into right and left lobes for transplantation has been investigated as a way to increase the supply of donor organs. | * Splitting livers into right and left lobes for transplantation has been investigated as a way to increase the supply of donor organs. | ||
* Approximately 20 percent of donors could be split. | * Approximately 20 percent of donors could be split. | ||
* Five-year survival rates were 77 percent, with graft survival rates of 76 percent. | * Five-year [[survival rates]] were 77 percent, with graft survival rates of 76 percent. | ||
* For children, 5-year survival rates were 75 percent, with graft survival rates of 63 percent. | * For children, 5-year survival rates were 75 percent, with graft survival rates of 63 percent. | ||
==== Marginal liver grafts ==== | |||
Marginal liver grafts | * The shortage of liver grafts has led to the relaxing of selection criteria for donors to ensure that as many potential recipients as possible are offered transplantation. | ||
* Many donor organs which were previously not considered suitable are now used. | |||
* The term marginal was originally applied to grafts from older donors, however, that definition has changed and now it is used to refer to grafts from a higher risk group of donors based on demographic, clinical, laboratory, and histological data. | |||
* There is a balance that needs to be achieved between access to [[grafts]], deaths on the waiting list, and [[Survival rate|survival]] after transplantation. | |||
* Marginal liver grafts donors include those with any of the following characteristics:<ref name="pmid28657945">{{cite journal| author=Halazun KJ, Quillin RC, Rosenblatt R, Bongu A, Griesemer AD, Kato T et al.| title=Expanding the Margins: High Volume Utilization of Marginal Liver Grafts Among >2000 Liver Transplants at a Single Institution. | journal=Ann Surg | year= 2017 | volume= 266 | issue= 3 | pages= 441-449 | pmid=28657945 | doi=10.1097/SLA.0000000000002383 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28657945 }}</ref> | |||
* Liver donor age >70 years | * Liver donor age >70 years | ||
* Livers from [[hepatitis C]] positive donors | |||
* Livers from hepatitis C positive donors | * Livers with cold [[ischemia]] time >12 hours | ||
* Livers with cold ischemia time >12 hours | * Livers from donation after [[Sudden cardiac death|cardiac death]] donors | ||
* Livers from donation after cardiac death donors | * Livers with >30 percent [[steatosis]] | ||
* Livers with >30 percent steatosis | |||
* Livers split between two recipients | * Livers split between two recipients | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
Revision as of 17:58, 6 January 2018
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
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Liver trasnsplantation Microchapters |
Overview
Liver transplantation techniques includes left lobe transplantation, right lobe transplantation, split-liver transplantation, and marginal liver grafts. In left lobe technique, the left and middle hepatic veins, left hepatic artery, and left portal vein are dissected. Small portal vein branches are ligated. The left bile duct is divided. In right lobe technique, the right lobe fits correctly into the right subphrenic space, making the vascular anastomoses easier to perform. Right lobe grafts are prone to a variety of technical complications. After cholecystectomy, intraoperative ultrasound may be used to mark the position of the hepatic veins and portal branches. The right hepatic artery and right portal vein are dissected, followed by the retrohepatic vena cava, isolating the origin of the right hepatic vein. Marginal graft means grafts from a higher risk group of donors based on demographic, clinical, laboratory, and histological data. Marginal liver grafts donors include those with any of the following characteristics: Liver donor age >70 years, livers from hepatitis C positive donors, livers with cold ischemia time >12 hours, livers from donation after cardiac death donors, livers with >30 percent steatosis, and livers split between two recipients.
Liver transplantation techniques
Left lobe transplantation
- The left and middle hepatic veins, left hepatic artery, and left portal vein are dissected.[1]
- Small portal vein branches are ligated. The left bile duct is divided.
- Vascular and biliary structures entering segment 4 are divided or left intact.
- The parenchyma is transected and then the left hepatic artery and left portal vein are divided, releasing the graft.
- The middle hepatic vein is removed with the graft when a full lobectomy is performed.
Video shows left lobe transplantation steps
{{#ev:youtube|bVCJ5Fch2OU}}
Right lobe transplantation
- The right lobe fits correctly into the right subphrenic space, making the vascular anastomoses easier to perform.[2]
- Right lobe grafts are prone to a variety of technical complications.
- After cholecystectomy, intraoperative ultrasound may be used to mark the position of the hepatic veins and portal branches.
- The right hepatic artery and right portal vein are dissected, followed by the retrohepatic vena cava, isolating the origin of the right hepatic vein.
- The right bile duct is isolated, completing mobilization of the right lobe.[3]
- The liver parenchyma is transected using an ultrasonic scalpel.
- A portoportal anastomosis is then made between the donor right portal vein and the portal vein of the recipient.
Video shows right lobe transplantation steps
{{#ev:youtube|iNEcmYFRbfY}}
Split-liver transplantation
- Splitting donor livers into left lateral and extended right grafts for transplantation into a pediatric and an adult recipient.[4]
- Splitting livers into right and left lobes for transplantation has been investigated as a way to increase the supply of donor organs.
- Approximately 20 percent of donors could be split.
- Five-year survival rates were 77 percent, with graft survival rates of 76 percent.
- For children, 5-year survival rates were 75 percent, with graft survival rates of 63 percent.
Marginal liver grafts
- The shortage of liver grafts has led to the relaxing of selection criteria for donors to ensure that as many potential recipients as possible are offered transplantation.
- Many donor organs which were previously not considered suitable are now used.
- The term marginal was originally applied to grafts from older donors, however, that definition has changed and now it is used to refer to grafts from a higher risk group of donors based on demographic, clinical, laboratory, and histological data.
- There is a balance that needs to be achieved between access to grafts, deaths on the waiting list, and survival after transplantation.
- Marginal liver grafts donors include those with any of the following characteristics:[5]
- Liver donor age >70 years
- Livers from hepatitis C positive donors
- Livers with cold ischemia time >12 hours
- Livers from donation after cardiac death donors
- Livers with >30 percent steatosis
- Livers split between two recipients
References
- ↑ Broelsch CE, Whitington PF, Emond JC, Heffron TG, Thistlethwaite JR, Stevens L; et al. (1991). "Liver transplantation in children from living related donors. Surgical techniques and results". Ann Surg. 214 (4): 428–37, discussion 437-9. PMC 1358542. PMID 1953097.
- ↑ Marcos A, Fisher RA, Ham JM, Shiffman ML, Sanyal AJ, Luketic VA; et al. (1999). "Right lobe living donor liver transplantation". Transplantation. 68 (6): 798–803. PMID 10515380.
- ↑ Wachs ME, Bak TE, Karrer FM, Everson GT, Shrestha R, Trouillot TE; et al. (1998). "Adult living donor liver transplantation using a right hepatic lobe". Transplantation. 66 (10): 1313–6. PMID 9846514.
- ↑ Emond JC, Freeman RB, Renz JF, Yersiz H, Rogiers X, Busuttil RW (2002). "Optimizing the use of donated cadaver livers: analysis and policy development to increase the application of split-liver transplantation". Liver Transpl. 8 (10): 863–72. doi:10.1053/jlts.2002.34639. PMID 12360426.
- ↑ Halazun KJ, Quillin RC, Rosenblatt R, Bongu A, Griesemer AD, Kato T; et al. (2017). "Expanding the Margins: High Volume Utilization of Marginal Liver Grafts Among >2000 Liver Transplants at a Single Institution". Ann Surg. 266 (3): 441–449. doi:10.1097/SLA.0000000000002383. PMID 28657945.