The aim of the investigation was to assess the immediate and long-term results of the liver transplantation in patients with unresectable hepatic alveolar echinococcosis.Materials and Methods. 22 liver transplantations were performed in the Center for Surgery and Transplantology of the A.I. Burnazyan Federal Medical and Biophysical Center between January 2011 and December 2016 for unresectable liver disease. Liver segments (the right liver lobe in all cases) from living related donors were transplanted to 21 patients, a posmortal donor liver was transplanted to 1 female patient. 16 patients (72.7%) had parasitic invasion of the inferior vena cava. All operations were done in R0 variant. Reconstruction of the great vessels was performed by synthetic PTFE-conduits if autoplasty was not feasible.Results. The duration of surgery was 430 (390-480) min. The intraoperative blood loss amounted to 1,500 (1,300-2,200) ml, cold ischemia lasted 30 (25-45) min. The morbidity rate of postoperative complications made up 45.4%. Biliary complications (Grade A, B, ISGLS, 2011) prevailed. Mortality rate was equal to 4.5%. The length of postoperative hospital stay averaged out to 20 (15-23.5) bed days. Long-term survival rate comprised 100%. Maximal follow-up period was 58 months.Conclusion. Liver transplantation with resection and reconstruction of the great vessels, including resection of the inferior vena cava and even the right atrium, may be the only radical method of treating unresectable hepatic alveolar echinococcosis, making it possible to provide satisfactory immediate and long-term results of surgical treatment of the patients seemingly doomed to death. These interventions should be performed only in highly specialized centers with a developed program of surgical hepatology and liver transplantation.
Rationale: Adult-to-adult right lobe living donor liver transplantation is a viable alternative to whole liver transplantation from a deceased donor. The key aspect of the surgical procedure is the restoration of adequate graft blood flow and maintenance of sufficient volume of well vascularized parenchyma in the donor. Specific features of vascular anatomy in the donor and the recipient can be eventual cause for significant technical difficulties during transplantation. They can also increase the risk of complications and deteriorate graft functioning.Aim: To identify the incidence of various types of afferent and efferent vascularization of right lobe of the liver, potential techniques of vascular reconstructive procedures, rates and types of postoperative complications, as well as immediate surgical results.Materials and methods: We retrospectively analyzed the data on 220 right lobe liver transplantations adult patients, consecutively performed from 2010 to 2017 in one center. Specific characteristics of liver vascularization in donors and recipients were determined by pre-operative computed tomography and intra-operatively. The information on the types of vascular reconstruction, complications and results of surgical procedures was obtained from patients' medical files.Results: The following variants of blood supply to the right liver lobe were seen most frequently: portal vein trifurcation 22%, shortened trunk of the right portal vein branch 13%, supplementary v. hepatica from SgVIII with a diameter of > 5 mm 22%, supplementary lower right v. hepatica 17%, isolated venous outflow from all right lobe segments 2%, two arteries 2%. In addition, 17% of the recipients had portal vein thrombosis and 1% portal vein fibrosis. During the follow-up all donors remained alive. The rate of surgical complications was 12.5%, among them bile pocket or biloma 8.5%, intra-abdominal bleeding 2.5%, wound complications 1.5%. The rate of early post-operative complications in the recipients was 31.5%, with 4.5% of them being vascular and 15.5% biliary. The 6-months and 4-years survival of the recipients (Kaplan-Meier) was 98% and 95%, respectively.Conclusion: Immediate and longterm survival of the recipients of living donor right lobe live grafts, as well as absence of fatalities among their donors, confirm high effectiveness and expedience of this type of intervention. The observed anatomic variety of blood supply to the right liver lobe stipulates stringent requirements to the quality of preoperative diagnostics, deliberate donor selection, thorough planning of the procedure and high qualification of the surgical team. A relatively high rate of postoperative complications warrants the necessity of an intensive diagnostic monitoring in the early post-operative period and active strategies of their correction.
Aim.To evaluate the possibilities and indications for ALPPS, immediate and long-term results of surgical treatment of alveolar echinococcosis including great vessels invasion in case of small remnant liver volume.Material and methods. There were 30 ALPPS procedures. Seven patients had small future liver remnant (FLR) — 24.5% (22.4—26.7%). Bile ducts repair with Roux-en-Y procedure for biliodigestive anastomosis during the first surgical stage was performed in 5 patients (71.4%). ALPPS combined with great vessels resection (portal vein or portal vein and left hepatic vein) was required in 4 patients (57.1%). RO-resections were carried out in all patients.Results.Mean duration of ALPPS stage I was 365 (330—415) min, intraoperative blood loss — 800 (700—1000) ml. Time of stage II was 85 (70—110) min, intraoperative blood loss — 200 (100—300) ml. The second stage of ALPPS was performed in 6—7 days (max 8 days) after preliminary assessment of FLR volume according to CT-volumetry, which was 570 (430—630) ml (37.9% (31.9—52.4%) in relation to FLR volume before the first stage of ALPPS. Augmentation of FLR volume was 200 (150—290) ml (60.9% (48.3—80.6%)). The daily increase of FLR volume was 29 (23—46) ml. Overall postoperative morbidity was 42.9% (complications grade I were noted in 2 patients (28.6%), grade IV — in 1 patient (14.3%). Incidence of post-hepatectomy liver failure grade A (ISGLS, 2011) after ALPPS stage II was 42.9% (n = 3). Bile leakage grade A (ISGLS, 2011) occurred in 28.6% of cases (n = 2). Mortality was absent. Postoperative hospital-stay after stage II was 22 (18—35) days. Maximum follow-up was 50 months. Long-term disease-free survival was 100%, median survival — 29 months.Conclusion.ALPPS technique is feasible, followed by desired increase of FLR volume and safe hepatectomy. The procedure leads to good immediate and long-term postoperative results in patients with alveolar echinococcosis and small FLR volume regard less invasion of afferent and/or efferent liver vessels.
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