Seigo Nishida

Transplantation of the abdominal wall

BACKGROUNDnClosure of the abdomen in patients undergoing intestinal transplantation can be extremely difficult, if not impossible. We describe our initial experience with abdominal wall allotransplantation to facilitate abdominal closure.nnnMETHODSnWe undertook nine cadaveric abdominal wall composite allograft transplants in eight patients. The grafts blood supply was based on the inferior epigastric vessels left in continuity with the donor femoral and iliac vessels. Skin biopsies were undertaken randomly and when rejection was suspected. Vessel patency was monitored by doppler ultrasound.nnnFINDINGSnSix patients have survived, five of whom have intact, viable abdominal wall grafts. Two patients have had a clinically mild episode of acute rejection of the skin of the abdominal wall that resolved with corticosteroid therapy. No clinically apparent graft-versus-host disease has been noted.nnnINTERPRETATIONnTransplantation of an abdominal wall composite allograft can facilitate reconstruction and closure of the abdominal compartment in intestinal transplant recipients with complex abdominal wall defects.

Piggyback technique in adult orthotopic liver transplantation: an analysis of 1067 liver transplants at a single center

BACKGROUNDnOrthotopic liver transplantation (OLT) in adult patients has traditionally been performed using conventional caval reconstruction technique (CV) with veno-venous bypass. Recently, the piggyback technique (PB) without veno-venous bypass has begun to be widely used. The aim of this study was to assess the effect of routine use of PB on OLTs in adult patients.nnnPATIENTS AND METHODSnA retrospective analysis was undertaken of 1067 orthotopic cadaveric whole liver transplantations in adult patients treated between June 1994 and July 2001. PB was used as the routine procedure. Patient demographics, factors including cold ischemia time (CIT), warm ischemia time (WIT), operative time, transfusions, blood loss, and postoperative results were assessed. The effects of clinical factors on graft survival were assessed by univariate and multivariate analyses.In all, 918 transplantations (86%) were performed with PB. Blood transfusion, WIT, and usage of veno-venous bypass were less with PB. Seventy-five (8.3%) cases with PB had refractory ascites following OLT (p=NS). Five venous outflow stenosis cases (0.54%) with PB were noted (p=NS). The liver and renal function during the postoperative periods was similar. Overall 1-, 3-, and 5-year patient survival rates were 85%, 78%, and 72% with PB. Univariate analysis showed that cava reconstruction method, CIT, WIT, amount of transfusion, length of hospital stay, donor age, and tumor presence were significant factors influencing graft survival. Multivariate analysis further reinforced the fact that CIT, donor age, amount of transfusion, and hospital stay were prognostic factors for graft survival.nnnCONCLUSIONSnPB can be performed safely in the majority of adult OLTs. Results of OLT with PB are as same as for CV. Liver function, renal function, morbidity, mortality, and patient and graft survival are similar to CV. However, amount of transfusion, WIT, and use of veno-venous bypass are less with PB.

Gastroduodenal artery steal syndrome during liver transplantation: intraoperative diagnosis with Doppler ultrasound and management.

Arterial steal syndrome (ASS) after liver transplantation has been reported. ASS causes arterial hypo‐perfusion of the graft liver and devastating consequences. However, the diagnosis tends to be delayed. We present the recognized case of a gastroduodenal artery (GDA) steal syndrome that was diagnosed with intraoperative Doppler ultrasound and treated with GDA ligation during the liver transplantation. The patient had variation of hepatic artery anatomy (low bifurcation of the hepatic artery). Graft liver had the common hepatic artery and aberrant left hepatic artery. Doppler ultrasound of the liver was performed after the arterial reconstruction between the donor common hepatic artery and recipient right hepatic artery. It showed low hepatic arterial flow. There is no backflow bleeding from the donor aberrant left hepatic artery stump. After ligating big GDA, hepatic arterial waveform inside the liver drastically improved and strong backflow bleeding was recognized from the donor left aberrant hepatic artery stump. The current case should show the efficacy of intraoperative Doppler ultrasound of the liver on ASS and alert clinician to ligate GDA to prevent ASS if hepatic arterial flows are suboptimal.

Internal hernia of the small bowel around infrarenal arterial conduits after liver transplantation.

Nishida S, Pinna AG, Nery JR, Levi D, Kato T, Madariaga J, Tzakis AG. Internal hernia of the small bowel around infrarenal arterial conduits after liver transplantation. Clin Transplant 2002: 16: 334–338.