Hepatic artery reconstruction using an operating microscope in pediatric liver transplantation—Is it worth the effort?

Abstract

Introduction In pediatric liver transplantation (pLT), hepatic artery thrombosis (HAT) is associated with inferior transplant outcome. Hepatic artery reconstruction (HAR) using an operating microscope (OM) is considered to reduce the incidence of HAT. Methods HAR using an OM was compared to a historic cohort using surgical loupes (SL) in pLT performed between 2009 and 2020. Primary endpoint was the occurrence of HAT. Secondary endpoints were 1‐year patient and graft survival determined by Kaplan–Meier analysis and complications. Multivariate analysis was used to identify independent risk factors for HAT and adverse events. Results A total of 79 pLTs were performed [30 (38.0%) living donations; 49 (62.0%) postmortem donations] divided into 23 (29.1%) segment 2/3, 32 (40.5%) left lobe, 4 (5.1%) extended right lobe, and 20 (25.3%) full‐size grafts. One‐year patient and graft survival were both 95.2% in the OM group versus 86.2% and 77.8% in the SL group (p = .276 and p = .077). HAT rate was 0% in the OM group versus 24.1% in the SL group (p = .013). One‐year patient and graft survival were 64.3% and 35.7% in patient with HAT, compared to 93.9% and 92.8% in patients with no HAT (both p < .001). Multivariate analysis revealed HAR with SL (p = .022) and deceased donor liver transplantation (DDLT) (p = .014) as independent risk factors for HAT. The occurrence of HAT was independently associated with the need for retransplantation (p < .001) and biliary leakage (p = .045). Conclusion In pLT, the use of an OM is significantly associated to reduce HAT rate, biliary complications, and graft loss and outweighs the disadvantages of delayed arterial perfusion and prolonged warm ischemia time (WIT).

Long‐term results of liver transplantation for maple syrup urine disease: A single‐center experience in Turkey

“…The reported risk factors for hepatic artery complications are LDLT and standard suturing instead of microsurgical reconstruction 21 . Using an operative microscope instead of a surgical loupe in hepatic artery reconstruction significantly reduces the risk of hepatic artery thrombosis 22 . In the recent study, hepatic artery stenosis was observed in 2 LDLT (right lobe liver graft) recipients and hepatic artery thrombosis was observed in 2 LDLT (left lateral lobe liver graft) and 1 DDLT (whole liver graft) recipients.…”

“…21 Using an operative microscope instead of a surgical loupe in hepatic artery reconstruction significantly reduces the risk of hepatic artery thrombosis. 22 In the recent study, hepatic artery stenosis was observed in 2 LDLT (right lobe liver graft) recipients and hepatic artery thrombosis was observed in 2 LDLT (left lateral lobe liver graft) and 1 DDLT (whole liver graft) recipients. We were using surgical loupe for hepatic artery reconstruction before mid-2016.…”

Over 30 Years of Pediatric Liver Transplantation at the Charité—Universitätsmedizin Berlin

“…For hepatic artery reconstruction, we saw great results with the reconstruction of the hepatic artery under the microscope, that led to an arterial thrombosis rate of 0%. Considering our previously published analysis, where hepatic artery thrombosis was the major risk factor for the worse outcome after pediatric LT [13], this is especially relevant. Nonetheless, overall modernization (e.g., by the means of much more sensitive ultrasound scans), improved antibiotic regimens, including antibiotic stewardship [46], and meticulous follow-up care will have impacted these results as well.…”

“…Thus, based on data availability as well as procedural and staff changes, we defined three historic cohorts (1991-2004, 2005-2014 and 2015-2021). As previously reported [13], vascular anastomoses for especially small artery diameters were routinely carried out under a surgical microscope by a plastic surgeon, and the interdisciplinary collaboration between pediatric hepatologists, intensive care unit specialists and transplant surgeons was intensified and formalized as of 2015.…”

The role of reconstructive microsurgeons in liver transplantation—a narrative review

“…Multiple studies have compared hepatic artery reconstruction with surgical loupes versus operating microscope. While it has been reported that microsurgical anastomosis using operating microscope significantly reduced the rate of hepatic artery thrombosis in some studies ( 45 - 48 ), others found little notable differences compared to using surgical loupes ( 49 , 50 ). Table 2 summarizes these studies.…”