Erdal Anadol

Hemodynamic Effect of Transdermal Glyceryl Trinitrate on Newly Constructed Arteriovenous Fistula

Transdermal glyceryl trinitrate (GTN) administration may have a beneficial effect in the creation of an arteriovenous fistula (AVF) by increasing blood flow through the access and by inhibiting platelet aggregation. We evaluated the hemodynamic effects of transdermal GTN administration on newly constructed arteriovenous fistula. Radiocephalic fistula at the wrist (Brescia fistula) was constructed as the initial vascular access in 31 uremia patients (study = 16, control = 15). The patient demographics and the etiology of chronic renal disease were similar in the two groups. None of the patients had severe vasculitis. The mean duration of chronic renal disease was 8 months (1–24 months). The diameter, blood flow rate, and blood output at the drainage vein and the subclavian vein were measured by duplex ultrasonography 24 hours after the procedure. The measurements were performed again with transdermal GTN (10 mg/24 hours adhesive patch) administration in the study group and, without any medication, in the control group 4 hours after the initial measurements were taken. In the study group, all of the hemodynamic parameters were significantly increased over the initial measurements (p <0.05) whereas in the control group all hemodynamic parameters were unchanged, except the diameter of the subclavian vein (p <0.05). The actual change in hemodynamic parameters was significant in the study group when compared to the control group (p <0.05). Our data showed that transdermal GTN administration at the forearm increases flow through the Brescia fistula.

Could the use of interposition grafts for arterial reconstruction be avoided by more caudate graft placement in living donor liver transplantation

One of the major challenges in living donor liver transplantation (LDLT) is short and small vessels (particularly the hepatic artery), particularly in segmental liver grafts from living donors. In the present study we report an alternative surgical technique that avoids interpositional vessel grafts or tension on the connection by anastomizing the allograft hepatic vein to the recipient inferior vena cava in a more caudate location. From March 2000 to January 2003, 28 patients (11 women/17 men) underwent 28 LDLT. Until June 2001, the preferred technique for hepatic vein anastomosis was end-to-end anastomosis between the allograft hepatic vein and the recipient hepatic vein (HV-HV) (n = 10). Thereafter an end-to-side anastomosis was performed between allograft hepatic vein and recipient inferior vena cava (HV-IVC) (n = 18). The level of venotomy on the recipient vena cava was decided according to the pre-anastomotic placement of the allograft in the recipient hepatectomy site with sufficient width to have an hepatic artery anastomosis without tension or need for an interposition graft during hepatic artery and portal vein anastomoses. Except the right lobe allograft with anterior and posterior portal branches, all portal and hepatic artery anastomoses were constructed without an interposition graft or tension in the HV-IVC group. Only one hepatic artery thrombosis developed in the HV-IVC group. As a result, this technique may avoid both hepatic artery thrombosis and the use of interposition grafts in living donor liver transplantation.

Living related right lobe liver transplantation at Ankara University

HE unique surgical anatomy of the liver allows it to be separated into independent anatomic units that can be transplanted. With the recent surgical innovations, livingrelated right lobe liver transplantation (LDRLT) is becaming the main source of organ supply for adult recipients in countries with a shortage of cadaver donors. PATIENTS At Ankara University Medical School, we performed 5 LDRLT in the last 16 months. Two of the donors were mothers, 2 were sisters, and 1 was a cousin. The donors were 44, 45, 46, 36, and 23 years old. The volumes of the right lobe grafts were 810, 860, 980, 650, and 1,000 mL. Four grafts had 2 bile ducts while the third one had 3. All grafts had single right hepatic vein and right hepatic artery, while 1 graft had separate anterior and posterior portal branches that required a cadaveric iliac vein graft for reconstruction. One donor received only autologous blood transfusion, while the last case was performed without any transfusion. The average donor heterologus blood transfusion was 1,150 mL for the other 3 donors. One donor experienced a transfusion reaction, with serious intravascular hemolysis that required plasma exchange. None of the donors experienced a surgical complication. The recipient ages were 22, 23, 35, 36, and 27 years. Etiology for recipient cirrhosis were Wilson’s disease, autoimmune hepatitis, and hepatitis B (3 cases). After recipient hepatectomy with preservation of the vena cava, hepatic veins were oversewn and right hepatic veins were anastomosed directly to a separate incision on the vena cava. No accessory hepatic veins or posterior hepatic vein anastomoses were done. Hepatic artery anastomoses were done under 2.5 loop magnification. One patient required an infrarenal aorto-hepatic artery saphenous vein interposition graft. In 4 patients, temporary end-to-side portocaval anastomoses were constructed for portal decompression using the right branch of the portal vein. Bile ducts were anastomosed to a Roux-Y limb over an external stent.